Responsible for verifying insurance coverage and obtaining appropriate insurance authorizations for all scheduled biologics, infusion and other injectable medications for new and established patients.
1. Serves as point of contact for authorizations and related insurance questions for all biologics, infusion and medications.
2. Reviews, prioritizes and completes authorizations and referral requests of medications daily for patients. Manages tight deadlines and maintains constant communication with Clinic to ensure timely approval of services and avoid missed authorizations.
3. Responsible for the identification and proper data entry of insurance demographics. Verifies specialty outpatient and inpatient insurance, both primary and secondary coverage (when applicable by service type), within set timeframes determined by Administrative Services Management. Verification includes obtaining and documenting covered and non-covered benefits, plan type, co-payment, co-insurance, out of pocket, and deductible amounts and determining contract and benefit eligibility.
4. Responsible for notifying the Patient Financial Counseling Office of any significant gaps in coverage and/or high co-pays or deductibles prior to services being rendered. Coordinates drug co-pay assistance programs with Clinic and Patient Financial Counseling Office.
5. Documents authorizations or denied authorizations in appropriate systems as per department protocol. Responsible for conducting clinical screening and providing all required medical information to insurance companies, as necessary to facilitate the authorization process.
6. Maintains a thorough understanding of all major insurance plans and medications prescribed by National Jewish and medical terminology and coding practices.
7. Educates clinical team regarding patient insurance requirements and limitations.
8. Maintains communications with patients to keep them apprised of their insurance authorization and eligibility status. Acts as a problem solver with patients regarding their insurance plan.
9. Coordinates the authorization appeal process for medications that are deemed not medically necessary. Refers cases requiring additional clinical review to National Jewish faculty and plan directors to ensure medications have all necessary approvals before administrating medications.
10. Coordinates retroactive authorizations with medical staff, ancillary departments and insurance plans as necessary.
1. Accountability: Accepts full responsibility for self and contribution as a team member; displays honesty and truthfulness; confronts problems quickly; displays a strong commitment to organizational success and inspires others to commit to goals; demonstrates a commitment to National Jewish Health.
2. Attention to Detail: Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time. Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence rather than having standards imposed.
3. Collaboration/Teamwork: Cooperates with others to accomplish common goals; works with employees within and across his/her department to achieve shared goals; treats others with dignity and respect and maintains a friendly demeanor; values the contributions of others.
4. Customer Focus: Ensuring that the customer perspective is a driving force behind business decisions and activities; crafting and implementing service practices that meet customers’ and own organization’s needs.
5. Managing Work and Time/Project Management: Effectively managing one’s time and resources to ensure that work is completed efficiently. Effectively manages project(s) by appropriately focusing attention on the critical few priorities; effectively creates and executes against project timelines based on priorities, resource availability, and other project requirements (i.e., budget); effectively evaluates planned approaches, determines feasibility, and makes adjustments when needed.
6. Peer Relationships: Interacts with others in a constructive, positive, and respectful manner, regardless of individual differences. Assists team members or co-workers in achieving personal goals and completing assignments.
Supervisory or Managerial Responsibility
1. Be available to work as scheduled and report to work on time.
2. Be willing to accept supervision and work well with others.
3. Be well groomed, appropriately for your role and wear ID Badge visibly.
4. Be in compliance with all departmental and institutional policies, the Employee Handbook, Code of Conduct and completes NetLearning by due date annually.
5. Fosters an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the institution.
6. Adheres to safe working practices and at all times follows all institutional and departmental safety policies and procedures.
7. Wears appropriate PPE as outlined by the infection control policies and procedures.
8. Demonstrates compliance with all state, federal and all other regulatory agency requirements.
High School Diploma or equivalent required. Associate’s degree preferred.
A minimum of three (3) years of recent insurance related experience within a healthcare environment required.
Special Training, Certification or Licensure