Description

The Insurance Authorization Coordinator I is responsible for obtaining authorizations for hospital-based and/or physician-based services.

The Coordinator utilizes work queues & other mechanisms to initiate the authorization and/or referral, follow-up, monitor appointments add-ons, and document any changes available for the initial authorization and/or referral request. Authorizations/Referrals for services are to be completed based on the departmental goals and guidelines set. The position is required to utilize all available resources to verify eligibility, authorization requirements and plan benefit levels. Detailed benefit collection process to ensure capture of patient responsibility to include all financial out to pocket cost to patient/parent. Process supports and ensures more accurate financial collections.

Primary Responsibilities:

1. Authorization Coordination: Ability to request and obtain preauthorization for assigned specialties and ability to cover for other workflows including workqueue items. This will involve submitting required documentation, following up on requests to ensuring timely approvals.
2. Ensure request for authorizations and notifications are worked timely and handled in accordance with departmental policy and payer requirements. Following all documentation requirements.
3. Insurance Verification: Verify patients insurance coverage, eligibility, demographics, benefits and financial responsibility to determine if prior authorization is required for specific medical procedures or treatments; additionally any predetermination requirements to ensure proper payment for service to support collection accuracy & efforts.
4. Policy Knowledge: Stay up to date with insurance policies, guidelines, and procedures related to authorization and reimbursement processes. This includes understanding specific requirements for different insurance companies and their medical coverage policies.
5. Properly process appointment or appt add-ons, changes to previously scheduled services, date changes, and or impactful service changes in need of immediate review.
6. Follow administrative review process if a service does not have an insurance authorization outside of the departments standard timeframe.
7. Communication: Communicate with patients, their families, and healthcare professionals to provide updates on the status of authorization requests, address questions or concerns, and ensure a smooth process for all parties involved.
8. Promptly review clinical documentation for necessary information to submit to the payer along with authorization request.
9. Documentation and Record-Keeping: Maintain accurate and detailed records of authorization requests, approvals, denials, and any related correspondence. This includes documenting patient information, insurance details, and the authorization process itself.
10. Collaboration: Collaborates with healthcare providers, physicians, and clinical staff, additionally the Central Business Office, Financial Services, Transport, Patient Cost Estimation, Managed Care, Utilization Review, dedicated Authorization Departments, and other departments that have impact on obtaining authorizations and/or reimbursement.
11. Problem-solving: Identify and address any barriers or challenges that may arise during the authorization process. This could involve working with insurance companies to resolve denials, appealing decisions, or finding alternative solutions for patients medical needs.
12. The Specialist will attend and participate in daily departmental huddles to report on payer issues, barriers affecting workflows, and specific issues that could result in a non-reimbursable or canceled service.
13. The Specialist must be organized, work effectively in a virtual team environment, can problem solve, and seek assistance when needed.
14. Build and maintain professional, cooperative relationships with contacts from specialty departments. Consistently demonstrates excellent, empathetic, and knowledgeable customer service skills to internal and external customers.
15. Compliance: Adhere to relevant laws, regulations, and privacy guidelines when handling patient information and insurance-related documentation. Ensure all authorization processes are conducted ethically and in accordance with organizational policies.

Requirements:

One year of specialized training beyond high school

Minimum of 6 months Insurance Authorization experience required

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding childrens hospitals Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Learn more at Nemours.org.