Authorization and Cost Estimate Specialist Associate - Remote - Full Time - Days

The Insurance Authorization & Cost Estimate Specialist is responsible for collecting necessary insurance benefit and clinical information to properly authorization the ordered service with the patient’s insurance company.  This includes steps to support insurance and benefit verification, pre-certification, and pre-authorization processes. 

 

The specialist must have clinical knowledge of services so appropriate information can be communicated/given to the insurance company which will ensure the service is rendered in the correct level of care. Reimbursement for the service rendered is dependent upon the insurance benefit verification process and meeting the authorization requirements of the insurance company.  

 

The specialist must also determine when the patient is under-insured so that additional funding sources can be evaluated and applied.

 

Once authorized, the specialist determines the cost for the service by applying the patient benefits / coverage information and estimate functionality accessible through IT applications.   This process is essential to ensuring the patient understands their financial responsibilities for the service rendered. This is a very dynamic environment as insurance plans, benefits, and coverage structures change frequently and the turnaround is essential so that treatment is not delayed. 

 

This individual will need expert knowledge of insurance plans, insurance regulations, and insurance benefit and coverages as they relate to the service rendered.  Additionally, this team serves as a point of contact within the organizations for questions and issues as they relate to insurance plans and coverage information.

 

The duties and responsibilities this individual performs is solely dependent on the organization receiving reimbursement for the service rendered and ensuring the patients cost are clearly identified.

Insurance Authorization

• Utilizes online systems, phone communication, and other resources to verify eligibility and benefits, determine extent of coverage, secure pre-authorizations, and determine patient liabilities within a timeframe before scheduled appointments determined by The Christ Hospital Health Network and during or after care for unscheduled patients
• Verifies medical necessity in accordance with the Centers for Medicare & Medicaid Services (CMS) standards, and communicates relevant coverage/eligibility information to the patient
• Coordinates benefits by effectively determining primary, secondary, and tertiary liability when needed
• Obtains pre-certifications and pre-authorizations from third-party payers in accordance with payer requirements
• Provides collections team with personalized patient estimates of financial responsibility based on insurance coverage or eligibility for government programs
• Remains updated on rates and changes to pricing/estimation system as necessary in order to ensure price estimates remain accurate
• Alerts physician offices to issues with verifying insurance and/or obtaining pre-authorizations
• Demonstrates  understanding of insurance terminology (e.g., co-payments, deductibles, allowances, etc.), and analyzes information received to determine patients’ out-of-pocket liabilities
• Connects patients with financial counselors when further explanation or education is needed or requested regarding payment plans or financial assistance; may conduct some basic financial counseling duties as necessary

 

Communication

• Communicates with patients, physicians, clinicians, front-end staff, or translators to obtain missing patient demographic or insurance information
• Communicates liabilities directly to patients and provides education on key insurance terms and rules; may often handle patients with more complicated insurance plans (e.g., workers’ compensation)
• Maintains excellent relationships with physician’s offices, insurance companies and other hospital departments.

 

Estimates

• Provides collections team with personalized patient estimates of financial responsibility based on insurance coverage or eligibility for government programs
• Communicates liabilities directly to patients and provides education on key insurance terms and rules; may often handle patients with more complicated insurance plans (e.g., workers’ comp)

 

Education

• Remains updated on payor requirements and rates and changes to pricing for estimates.

KNOWLEDGE AND SKILLS: 

 

EDUCATION: High School Diploma or GED required. Associate or bachelor’s degree in healthcare administration or related preferred.

          

YEARS OF EXPERIENCE:  One to two years of registrat