Insurance Authorization Specialist Job Description

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Author: Lisa
Published: 7 Jul 2021

A Certificate Program in Medical Coding and Billing, A note on the costs of specialist visits, Emergency Situations, An Insurance Verification Specialist with Experience in Hospital Billing and more about insurance authorization specialist job. Get more data about insurance authorization specialist job for your career planning.

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A Certificate Program in Medical Coding and Billing

You need a high school degree and specialized training for the industry in which you work to become an authorization specialist. If you are working in the medical insurance industry, you may need a certificate program in medical coding and billing from a community college or a school. Strong customer service skills, as well as excellent administrative abilities, are important skills for the position.

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A note on the costs of specialist visits

If you received authorization from your insurance company, you should ask the specialist if they received it. If they have not, you should contact your insurance company to see if they have authorized the visit. If they don't have any records of an authorization, you should call your doctor to verify they submitted the request.

Know your health insurance requirements. If you need to see a specialist, you should contact your doctor to get the best possible reimbursement. If you don't have an authorization before your first visit, your insurance company may not cover the cost of the visit or they may back date it.

Emergency Situations

Important note. In an emergency situation, no prior authorization is required. An emergency is an instance in which the absence of medical attention could endanger a person's life, health, or ability to regain maximum function, or cause a person to suffer a severe pain.

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An Insurance Verification Specialist with Experience in Hospital Billing

A high school degree is required to become an insurance verification specialist. Employers prefer candidates with a few years of experience working in a hospital admissions or billing setting. Competitive applicants have a good knowledge of medical terminology and are familiar with hospital billing policies and procedures.

Automating Preauthorization for Cost-of Care Management

Preauthorization is a utilization management practice used by health insurance companies that requires certain procedures, tests and medications to be evaluated to assess the medical necessity and cost-of-care ramifications before they are authorized. If a health insurance payer rejects a prescribed course of treatment, it will affect whether a provider or pharmacy will be reimbursed for the full or partial amount of the claim. One of the main reasons that prior authorizations take so long to resolve is that incomplete or incorrect information is submitted to the health plan, which causes a denial and a lot of manual re-work on the provider side.

Errors in the prior authorization form can flag it for denial. A number on a patient's health ID card may be different. A middle initial may be wrong.

An address may be incomplete. The prior authorization process can be too complex and involve a lot of manual steps, which can make it ripe for mistakes. If any of the information is not accurate, the denial will be made.

It is difficult to reverse a denial. Automating the end-to-end prior authorization process early in the revenue cycle reduces the likelihood for errors, reduces the amount of manual work wasted, and speeds patient care. The decision a prior authorization request rests with a clinician who works for the health plan that submitted the request.

The clinician at the insurance carrier makes the final decisions. For more expensive, involved treatments, prior authorizations are usually required. Preauthorization is required for an procedure such as orthopedic surgery.

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The Clinical Referral Specialist

The referral specialist makes sure patients are cleared for specialty service office visits. Pre-certification, registration and case related concerns are resolved prior to a patient's appointment. Being a Referral Specialist gathers information from insurance carriers, financial counselors, and other ancillary staff to make sure the patient's financial obligations are met.

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