Clinical Authorization Specialist - High Tech Radiology

POSITION DESCRIPTION:

Responsible for reviewing, submitting, monitoring and responding to issues regarding medical necessity prior authorizations for high tech radiology services, procedures and/or DME (Durable Medical Equipment) for IHA patients in multiple offices. Reviews patient medical history to identify supporting documentation in the patient chart relevant to the service or procedure; contacts insurance companies and obtains authorization.

ESSENTIAL JOB FUNCTIONS

• Responsible for reviewing, submitting, monitoring and responding to issues regarding prior authorizations for high tech radiology services, procedures, and/or DME.
• Professionally communicates (oral or written) with the ordering provider for next steps, practice support staff and representatives of insurance companies.
• Reviews patient medical history, labs, pathology, imaging reports, ED records, consultations, etc. to identify supporting documentation in the patient chart relevant to the testing being ordered.
• Performs data collection and data review assignments as required.
• Contacts insurance companies or appropriate third party and obtains authorizations.
• Updates information in patient medical record (EMR) with approval or denial information; follows up with ordering physician as to status and/or issues with prior authorizations.
• Monitors in-basket, email and fax server if applicable. Follows up on correspondence timely and accurately.
• Obtains urgent authorizations same day, next day.
• Verify correct procedural codes, diagnostic codes and insurance verification.
• Monitors authorizations or denials and follows up, as necessary.
• Contacts insurance companies or appropriate third party and obtains authorizations.
• May act as a mentor to other team members.
• May assist with ongoing training of new and existing staff.
• Supports other offices, attends required meetings and trainings, and participates in committees as requested.
• Performs other duties and participates in special projects, as assigned.

ORGANIZATIONAL EXPECTATIONS:

• Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of Trinity Health Medical Group.
• Must be able to work effectively as a member of the Call Center team.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
• Successfully completes all relevant organizational training and adheres to Trinity Health Medical Group standard of care as outlined in the Trinity Health Code of Conduct.
• Maintains knowledge of and complies with Trinity Health Medical Group standards, policies and procedures.
• Maintains general knowledge of Trinity Health Medical Group office services and in the use of all relevant office equipment, computer and manual systems.
• Maintains strict confidentiality in compliance with Trinity Health Medical Group and HIPAA guidelines.
• Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences.
• Uses resources efficiently.
• If applicable, responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

ESSENTIAL QUALIFICATIONS:

EDUCATION: Undergraduate degree or Associate’s degree in healthcare or graduate of an accredited LPN, PTA, Radiology Technician or Technologist, Respiratory Therapy, Ultrasound or Medical Assistant program.

CREDENTIALS/LICENSURE:

Valid, unrestricted LPN license in the State of Michigan;

Valid, unrestricted Physical Therapy Assistant license in the State of Michigan;

Valid, unrestricted Respiratory Therapist license in the State of Michigan;

Radiology Technician or Technologist Certification;

Ultrasound Technician Certification; or

Certification as a Medical Assistant through one of the following certifying agencies:

• American Association of Medical Assistants (CMA)
• American Medical Technologists (RMA)
• National Center for Competency Testing (NCMA)
• National Healthcareer Association (CCMA)
• National Association of Health Professionals (NRCMA)
• American Medical Certification Association (CMAC)

MINIMUM EXPERIENCE: 1-3 years’ previous clinical experience; 3 to 5 years’ experience with insurance referrals, prior authorization or other relevant medical office experience.

POSITION REQUIREMENTS (ABILITIES & SKILLS):

• Proficient/knowledgeable in medical terminology.
• Proficient knowledge of major health plans and insurance processes.
• Knowledgeable in obtaining medical necessity authorizations for multiple offices.
• Strong knowledge in multiple imaging modalities.
• Strong knowledge in disease processes and the appropriate testing.
• Knowledgeable in ICD 10/CPT coding.
• Ability to perform mathematical calculations needed during the course of performing basic job duties.
• Proficiency in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records, Microsoft 365 office suite (strong Excel work), email, e-learning, intranet and computer navigation. Ability to use other software as required while performing the essential functions of the job.
• Ability to perform data collection and data review assignments.
• Ability to track pending authorizations for multiple offices.
• Ability to document steps, processes and procedures.
• Excellent communication skills in both written and verbal forms, including communications with insurance companies and proper phone etiquette. Ability to read, understand and respond to detailed written and oral instructions.
• Ability to speak before groups of people, either in-person or virtually.
• Ability to communicate effectively with medical offices, physicians and both clinical and clerical staff.
• Ability to work collaboratively in a team-oriented environment; displays courteous and friendly demeanor.
• Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, patients, vendors, family members, outside customers and community groups.
• Ability to cross-train in other areas of practice in order to achieve smooth flow of all operations.
• Good organizational and time management skills to effectively juggle multiple priorities, time constraints and ever-changing medical situations.
• Ability to exercise sound judgement and problem-solving skills.
• Knowledge of the compliance aspects of clinical care and patient privacy and best practices in medical office operations.
• Ability to handle patient and organizational information in a confidential manner.
• Successful completion of IHA competency-based program within introductory and training period.

MINIMUM PHYSICAL EXPECTATIONS:

• Physical activity that often requires keyboarding, phone work and charting.
• Physical activity that often requires time working on a computer.
• Physical activity that sometimes requires walking.
• Physical activity that sometimes requires lifting up to 5 lbs.
• Specific vision abilities required include close vision, depth perception, color vision, peripheral vision and the ability to adjust and focus.
• Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.
• Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.

MINIMUM ENVIRONMENTAL EXPECTATIONS:

This job operates in a typical office environment which involves frequent interruptions and significant interaction with people (some of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities.