The Clinical Authorization Specialist will take the lead in securing medical authorizations from third party payers (commercial and government) for outpatient clinic, inpatient admission, ancillary services and/or chemotherapy and other infused treatments as needed. The Specialist will be instrumental in obtaining written documentation, submitting tracking, reporting and documenting outcomes of each authorization request. The Specialist will be in a position to interface directly with medical/clinical staff and pharmacy to ensure a seamless process to the patients receiving treatment.
The Specialist – Clinical Authorization will take the lead in securing medical authorizations from third party payers (commercial and government) for outpatient clinic, inpatient admission, and ancillary services as needed. The Representative will be instrumental in obtaining written documentation, submitting, tracking reporting and documenting outcomes of each authorization request. The Representative will be in a position to interface directly with medical and clinical staff to ensure a seamless process to the patients receiving outpatient clinic, inpatient admission and /or ancillary services. This position is critical in maintaining an efficient patient flow with providing for an excellent patient experience. This position is responsible for scheduling all new patient visits and follow- up appointments, answers patient phone calls, prepares charts, and patient new consult questionnaires. In addition, this role will collaborate with other administrative personnel to assist with patient registration, insurance verification, insurance authorization.
Essential Duties:
- Actively obtain written clinical documentation in Keck care for authorization submission from Medical/Nursing Staff
- Submit pre-certification documentation to third party payers/payers insurance carrier for authorization/pre determination with correct CPT and ICD coding.
- Research payers medical policy requirements for treatment authorizations and understand process for submitting pre-certification requests
- Utilize Excel Macro tracking log to document authorization requests, follow-up on items and provide outcomes to the Supervisor daily prior to end of shift.
- Follow-up on outstanding authorization requests and on medical documentation requests in a timely manner
- Review schedule daily to identify patients scheduled for services that may require pre-cert or authorization.
- Communicate with medical/clinical staff and patients on authorization status/outcome.
- Coordinate with Director (or designee) on denied or disputed claims to obtain documentation to support ordered services
- Exhibit sensitivity to the patients at all times concerning privacy, and confidentiality while accessing medical records to process authorization requests for treatment
- Scan all authorizations into Keck care under the respective patient accounts
- Document authorization outcome in all financial systems.
- Scheduling new and follow up appointments.
- Performs other duties as assigned.
Required Qualifications:
- High school or equivalent Or equivalent evidence in file.
- 2 years 2 years of experience in a hospital, medical office/doctor’s office or working for a health insurer required.
- Excellent time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills
- Demonstrate excellent customer service behavior.
Preferred Qualifications:
- Ambulatory experience is preferred.
- Medical prior authorizations or claims experience in a managed care setting highly preferred
- Knowledge of the health insurance industry and claims processing a plus
- Knowledge of medical terminology.
- Knowledge of the health insurance industry and claims processing.
Required Licenses/Certifications:
- Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
The hourly rate range for this position is $25.00 – $39.69. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
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