Hospital Authorization Spec (Remote)

Nemours is seeking a Hospital Authorization Specialist to join our team in Wilmington, DE!

Schedule: Monday through Friday, 8:30 am to 5:00 pm.

The Specialist is responsible for obtaining and processing Elective, Urgent, and Emergent authorizations for all surgical and non-surgical admissions. The Specialist is also responsible for obtaining authorizations for Outpatient Surgery and selected Day Medicine and Outpatient services including co-payment collection. Elective authorizations are obtained prior to the admission/service date according to department standard and Emergent/Urgent notifications are to be initiated at the time of admission. During the authorization and notification process the Specialist will provide the payor with all patient information and requested documentation necessary to obtain admission approval. This role is required to utilize all available resources to verify eligibility, benefit levels, and patient copayment responsibilities. This position collaborates with: Care Management, Preadmission Specialist, ED Access Staff, Transport Staff, Physicians, and Departmental Administrative Staff to ensure that accurate information is collected and distributed effectively and efficiently. The Specialist utilizes daily reports and workqueues to complete follow up on non-approved cases and assure completion prior to admission date according to department standards. In addition, the Specialist will attend daily departmental huddles to report on payor issues, barriers impacting workflows, and specific issues that could result in a non-reimbursable visit. The Specialist is required to provide excellent, customer focused and efficient service to both internal and external customers and represent Nemours in a positive, professional manner. The Specialist will have the ability to cover most authorization types, participate in organizational committees/task forces, attend payor meetings and demonstrate effective utilization of EPIC applications as indicated by performance measures. This position will also assist with new associate training

Essential Functions:

• Ensure request for authorization is timely and handled in accordance with departmental policy and payer requirements.
• Accurately verify patient demographics, insurance eligibility, benefits, and financial responsibility.
• Ability of request and obtain preauthorization for assigned specialties and be able to cover for other specialties including workqueues, preadmissions, estimates, etc.
• Build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
• Contact families in person or by phone contact to obtain necessary information and assist them with insurance issues and/or handle direct PA and DE Medicaid newborn enrollment.
• Prepare estimates for scheduled services. Must interpret patient’s benefits correctly for accurate estimates.
• Clearly document all communications and contacts with payers, physicians, and families in standardized documentation requirements including proper format. Communicate effectively, timely and professionally in writing and verbally.
• Consistently demonstrates excellent, empathetic, and knowledgeable customer service skills to internal and external customers
• Collaborates with Financial Services for newborn enrollment, Medicaid enrollment/re-enrollment, self-pay referrals, estimates and Nemours funding.
• Follow all newly implemented workflows including those developed by Continuous Improvement projects. Participation in CI projects may be required as Supervisor/Manager determines.

Additional Requirements:

• Authorization experience required.
• High School Diploma required. Specialized (1 year of training beyond high school)
• Minimum 6 months of experience required.