Work Shift:

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview:

Call Center Authorization/Quality Specialist

JOB CODE:50847

FLSA Exemption Status:Non-Exempt

SUMMARY (BASIC PURPOSE OF THE JOB)

Ensures and completes authorization and auditing for outpatient testing services prior to services being rendered for optimal Performs tasks of position successfully as they directly impact denials and reimbursement. Maintains complete knowledge of the pre-registration/scheduling system and department operational procedures and training guidelines to identify and audit charts for accurate demographic, diagnosis, and insurance information for all scheduled tests. Uses knowledge and skills of pre-registration scheduling requirements and applies them during chart review. Reviews all required information to ensure chart is complete.

MINIMUM REQUIREMENTS

Education: High school diploma or GED.

Experience: Five years of experience in patient scheduling or in a medical office role working with patient insurance. Experience in insurance verification and authorization preferred.

Other Credentials:

Knowledge and Skills: Working knowledge of medical insurance plans. Proficiency in working with payors on-line portals, as well as Experian and Navinet preferred. Basic knowledge of medical terminology and diagnosis. Possesses strong skills in patient relations, pre-registration, scheduling, pre-certification, and auditing of all scheduled outpatient accounts.

Special Training: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to prepare and interpret bar graphs. Ability to utilize common sense understanding in order to carry out written, oral or diagrammed instructions.

Mental, Behavioral and Emotional Abilities: Ability to deal with problems involving several known variables in situations of a routine nature. Ability to effectively communicate information and respond to questions in person-to-person and small group situations with customers, clients, general public and other employees of the organization.

Usual Work Day:8 Hours  

REPORTING RELATIONSHIPS

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

• Uses knowledge and skills of pre-registration scheduling requirements and applies them during chart review. Reviews all required information to ensure chart is complete.
• Performs chart review to identify if variation from quality registrations exists. Determines the need for process improvement. Identifies concerns and makes recommendations for review to improve processes.
• Communicates findings as appropriate to department management involved. Reports discrepancies to supervisor or manager to ensure corrective action is taken in a timely manner.
• Maintains complete knowledge of the pre-registration/scheduling system and department operational procedures and training guidelines to identify and audit charts for accurate demographic, diagnosis, and insurance information for all scheduled tests.
• Secures insurance authorizations and pre-certifications for outpatient services. Verifies pre-certification to ensure appropriate reimbursement.
• Maintains proper communication skills with physician offices to obtain needed information for authorizations. Obtains and reviews physician orders for medically necessity coverage requirements.
• Assists with development and implementation of new or improved processes. Maintains up to date knowledge with Insurance matrix, pre-registration and scheduling compliance, insurance applications, and other systems utilized by Central Scheduling.
• Possesses proficiency with all insurance plans and payor codes. Identifies payment source and secures all information required to insure a billable and collectable account and avoid penalties or denials prior to the bill dropping.
• Maintains thorough understanding of payor requirements for authorization, pre-authorization, and referrals. Performs verification of benefi