Authorization & Clearance Specialist

Authorization & Clearance Specialist plays a critical role in ensuring that medical services provided to patients are covered by the patient's insurance providers.

Responsibilities include:

• Obtaining pre-authorizations and initiating authorizations
• Extending concurrent authorizations and initiating retroactive authorization modifications
• Verifying insurance coverage for medical procedures, treatments, and hospital stays
• Processing discharge notifications as appropriate
• Identifying valid coverage for an episode of care or specific service by contacting insurance companies and reviewing electronic response and coverage discovery information
• Submitting and following up on authorization requests with appropriate clinical documentation, CPT codes, ICD-10 codes, Tax ID, and NPI information
• Working daily work queues to prioritize authorization requests based on appointment time, medical severity, payer assignments, and dollar value
• Verifying covered benefits, restrictions, deductibles, out-of-network referrals, out-of-pocket limits, and lifetime/event caps
• Referring patients to Financial Counseling, Prior Authorization, or Billing as needed
• Using insurance discovery tools to validate coverage and coordination of benefits
• Communicating with physicians, clinical teams, Case Management, and patient representatives to obtain missing information and resolve pending authorizations
• Calculating patient financial responsibility using estimator tools and communicating out-of-pocket amounts due at service
• Coordinating self-pay package pricing and escalating complex pricing issues to the Managed Care team
• Processing patient payments in accordance with policy and maintaining payment integrity
• Scanning and uploading required documents into the documentation imaging system
• Supporting new system go-lives, department initiatives, onboarding, and training of team members
• Cross-training across service lines, payers, and departmental functions as needed