Physician Authorization/Referral Specialist

Nemours is seeking a Physician Authorization/Referral Specialist!

The Specialist is responsible for obtaining and processing Elective, Urgent, and Emergent referrals and authorizations for physician based services and some office based services, including but not limited to cardiology, audiology test, laboratory testing.

The Specialist is also responsible for obtaining genetic testing approval and medication authorizations and other assigned outpatient services.

The Specialist will work with partner hospitals for claim submission and registration accuracy.

They will also ensure that patient responsibility estimates are created and communicated timely.

Elective referrals and authorizations are obtained prior to the service date according to the department standard.

Urgent/Emergent referrals and authorizations are to be initiated at the time of the service and must be completed according to insurance company guidelines.

Referrals and authorizations are obtained prior to the date of service as per department standards.

During the authorization/referral process the specialist will provide the insurance company and or pcp office with all required patient information by fax, phone, or online submission.

They will partner with the Primary Care Provider to obtain all approvals as needed per insurance company requirements.

This role is required to use all utilize all available resources to verify eligibility, benefits and patient out of pocket responsibilities.

Estimates are prepared during the authorization process for in office testing and procedures.

The Specialist is also responsible for researching and notifying the servicing departments of co-payment responsibilities.

It is the very important that the Specialist understand and interpret benefits correctly in order to communicate and estimate out of pocket responsibility according to the patients insurance benefit.

Should a service date approach without prior authorization and or referral the specialist will follow the Administrative Approval process to ensure that patient responsibility is accounted for.

This position collaborates with: Hospital Authorization department, non Nemours physician offices, managed care department and Nemours Physicians, and Departmental Administrative Staff to ensure that accurate information is collected and distributed effectively and efficiently.

The specialist will collaborate with partner hospital to s=ensure that claims are processed timely and effectively.

They will also partner with outside resources such as Paths to ensure enrollment with Medicaid payers takes place timely.

The Specialist utilizes daily reports and work queues to complete follow up on non-approved cases and assure completion prior tto service date according to department standards.

In addition, the Specialist will attend daily departmental 2 huddles to report on payor issues, barriers impacting workflows, and specific issues that could result in a nonreimbursable visit.

The Specialist is re...