The RN Insurance Authorization Specialist obtains authorizations for all designated services at National Jewish Health and manages telephone communications with patients, families, and other members of the healthcare team. This position should be knowledgeable about all plan requirements for each payer for the specialty outpatient and inpatient hospital setting and is responsible for the submission of all authorizations requiring clinical support in the UM department.
- Maintains knowledge of all current procedural and diagnosis codes while utilizing provided resources to obtain new codes as payers change and coding requirements are updated.
- Reviews, prioritizes and completes authorizations and referral requests. Manages tight deadlines and maintains constant communication with clinic to ensure timely approval of services and avoid missed authorizations.
- 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.
- Maintains a thorough understanding of all major insurance plans as well as special requirements for the elective outpatient and inpatient hospital setting.
- Maintains a thorough understanding of medical terminology in order to identify information in the patient’s medical record that supports medical necessity.
- Coordinates the authorization appeal process for procedures that are deemed not medically necessary. Refers cases requiring additional clinical review to National Jewish Health faculty and plan directors to ensure all necessary approvals are obtained prior to care.
- Provides safe and appropriate patient care within scope of practice and established policies and procedures.
- Utilizes departmental processes of assessment, planning, implementation and evaluation to provide continuing health care to individuals, families.
- Performs in-take assessment, via telephone, to determine customers’ needs, reviews and provides current and accurate medical, program and research information; identifies those appropriate for potential admission; obtains a brief, concise intake history and facilitates admission process as required, following Policies & Procedures.
- Provides appropriate education to patients/families utilizing effective teaching skills, and National Jewish supportive materials.
- 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.
- 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.
- 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.
- 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.
- Initiative: Taking prompt action to accomplish objectives; taking action to achieve goals beyond what is required; being proactive.
- 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.
Supervisory or Managerial Responsibility
- Be available to work as scheduled and report to work on time.
- Be willing to accept supervision and work well with others.
- Be well groomed, appropriately for your role and wear ID Badge visibly.
- Be in compliance with all departmental and institutional policies, the Employee Handbook, Code of Conduct and completes NetLearning by due date annually.
- Fosters an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the institution.
- Adheres to safe working practices and at all times follows all institutional and departmental safety policies and procedures.
- Wears appropriate PPE as outlined by the infection control policies and procedures.
- Demonstrates compliance with all state, federal and all other regulatory agency requirements.
- Education: Associate’s degree in Nursing required. Bachelor’s degree in Nursing, preferred.
- Work Experience: Three years of clinical nursing experience required. Two years of prior authorization experience, preferred.
- Special Training, Certification or Licensure: Active Colorado Registered Nurse License required. Certified Healthcare Access Associate (CHAA), preferred.
Salary Range: $32.00 - $37.00