Manager Enterprise Authorization Services

Serves as the primary contact for coordinating and controlling all activities related to obtaining insurance prior authorization, and researching and analyzing denied services to ensure processes and workflows are created and implemented to minimize payment denials. Manages a team of authorization specialists responsible for insurance verification and the prior authorization of various assigned services.

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or Equivalent.

EXPERIENCE:

1. Five (5) years’ experience healthcare accounts receivables management, billing and collections.

2. Two (2) years of supervisory experience.

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in Finance, Business Administration or related field.

2. Certified Healthcare Financial Professional (CHFP) with the Hospital Financial Management Association (HFMA).

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Responsible for all aspects of managing and leading a team including: interviewing, hiring, training, developing, directing work processes, managing performance, managing time and attendance, and recognizing and rewarding employees.

2. Demonstrates ability to communicate effectively with hospital personnel.

3. Provides direct and timely communication to Departmental Directors and Clinic Administrators regarding revenue risks within their departments. Participates in process design that will mitigate identified risks.

4. Promotes collegiality, recognizes responsibilities and performs them willingly with positive impact on patients, coworkers, and external providers.

5. Reviews and manages productivity and timeliness of authorization and Develops/implements action plans appropriately.  Reports delays to Department Leadership.

6. Stays abreast of updates and changes to regulatory billing updates, regulatory requirements and organizational compliance policies to avoid audits and appeals/denials

7. Proactively works to maintain staffing levels, and reassigns work according to organizational priorities when necessary.

8. Manages and regularly audits the work of all Authorization staff to ensure high quality and productivity. Monitor and track staff compliance regarding timeliness of obtaining authorizations and treatment plan submission to ensure ongoing attention to timely processing accounts

9. Monitors data trends relating to insurance authorization and reimbursement and reports on such to Director

10. Identifies process improvement opportunities and develops, implements, monitors and revises action plans.

11. Anticipates and proposes opportunities to improve current technology to enhance performance and productivity.

12. Maintains a good working knowledge of authorization requirements for all payors and state/federal regulatory guidelines for coverage and authorization of outpatient services

13. Oversees pre-certification requirements for assigned services to create and implement necessary workflows and processes to improve system reimbursement.

14. Uses data analysis related to Denial Management metrics to monitor progress on denial and looks for process initiatives.

15. Works closely with hospital billing, professional billing, Outpatient Registration and Revenue Cycle in monitoring data trends relating to insurance authorization and reimbursement and handles complex denials. Responsible for leading multi-departmental efforts to resolve any barriers to completing authorizations and avoiding denials of payment.

16. Manages the functions of the assigned hospitals to ensure timely review, and facilitates the front end appeals through peer to peer.

17. Attends relevant meetings in and outside the hospital to represent pre-authorization services.

18. Analyzes new services for guidance regarding pre-authorization and denial reduction.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Considerable knowledge of computers and the use/manipulation/application of data in support of administrative functions.

2. Knowledge of EPIC system is preferred.

3. Knowledge of Medicare, Medicaid and other regulatory requirements.

4. Knowledge of UB-04, itemized bills, insurance plans (i.e. Commercial Medicare, Medicaid, HMO, PPO, etc.) grievance procedures and utilization management processes required.

5. Knowledge of managed care, inpatient and outpatient care, utilization management, Interqual criteria.

6. Knowledge of the operations of patient billing is required.

7. Knowledge of medical terminology and the ability to interpret information in the medical record is required.

8. Knowledge of CPT, ICD9/10, and DRGs.

9. Previous experience in administrative or supervisory role.

10. Effective organizational skills, attention to detail, ability to take initiative and excellent follow through a must.

11. Ability to function as a team player and support of colleagues and staff is essential.

12. Ability to hold others accountable to performance related to lost revenue due to denials.

United States of America (Exempt)

536 SYSTEM Hospital Authorization Unit