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The Pre-Authorization Radiology (PAR) Authorization and Financial Counselor is generally assigned to one primary work area within the Pre-Access Unit, but may rotate or be assigned to any area or site within the Patient Access Department as outlined in departmental expectations. With the primary assignment area being the PAR, the primary responsibility for the representative is obtaining authorizations for radiology exams/services by working with ordering physician’s office staff, the applicable Medical Center ancillary department, and/or review organization(s) as required. In general, the Authorization Counselor is responsible for all spectrums of financially securing the insurance and authorization data for patients’ services with insurance coverage that are primarily handled by the PAR Unit. The responsibilities include: 1) verifying basic demographic and clinical information relevant to the patient’s radiology exam/services 2) verifying insurance eligibility and benefits, 3) securing authorization from third party payers (and/or their designated review organizations), and 4) properly notating all activity in APeX.
Reports to the Pre-Access Supervisor
DUTIES & ESSENTIAL JOB FUNCTIONS
1. Responsible for obtaining authorizations for radiology exams or services by working with ordering physician’s office staff, the applicable Medical Center ancillary department, and/or review organization(s) as required.
2. Confirm patient insurance eligibility and benefits identifying any specific concerns that may delay the ability to secure authorization and update as necessary.
3. May require contacting patient over the phone to collect current patient demographic information and financial/insurance data and updating the patient’s account in order to submit authorization requests accurately.
4. Authorization Processing - Retrieves appropriate clinical information from APeX to provide to insurance. This may include outside results in APeX via Care Everywhere, and requests for external outside results. This information is relayed through completion of appropriate forms and submission of authorization requests for radiology exams ordered by Client physicians via fax, online submission, or telephone.
5. Facilitation of Peer-to-Peer Review – Monitors authorization status and follows authorization response/determination and responds appropriately to provide specific additional information as requested. Following the P2P Guideline, engages provider and provider offices if an alternative service/exam request is made by payor to determine acceptability or to determine if peer-to-peer (P2P) performed by clinicians at Client and insurance company is required.
6. Authorization Pending Status - Communicates with RadBilling and Radiology Scheduling when authorization requests remain PENDING one day prior to exam for follow up and requests medical urgency from provider when appropriate.
7. Payer Redirects - Communicates with Radiology Scheduling when patients are redirected by the payer to another facility and communicates with physician to ensure appropriateness of redirection. Provide patient with alternative facility information and orders.
8. Payer Member Outreach - Communicates with patient when Member Outreach by payer is triggered. Member outreach is when the exam is clinically approved but payer wishes to discuss options with patient. Tracks and follows up on authorization status to obtain final authorization.
9. Authorization Denials - Communicates with ordering physician, RadBilling, Radiology Scheduling, and patient regarding the authorization denial status. Self-pay may be an option at this point.
10. Patient High Deductible -Identifies patient liability/high-deductible and transfers to RadBilling for disposition.
11. Authorization Pre-Determination - If no authorization is required but payer pre-determination is available or required, referral is transferred to RadBilling workqueue for handling.
12. In cases that exams/services require to be rescheduled due to an authorization issue, protocol changes, patient request, or any other event, the PAR representative should ensure that all parties are informed including communicating with the patient, radiology scheduling and the provider’s office to ensure that proper follow up is maintained.
13. The PAR representative is required to enter complete authorization information in the referral activity screen documenting ongoing activity that may include all communication with patients, providers, payors, or other departments until final outcome is determined for the authorization.
14. The PAR representative will address the patient’s questions regarding the authorization process. They will refer any clinical queries to the nursing or physician staff, and escalate to PAR team lead and management any potential patient situations that may pose as service delivery challenges.
15. Meets the productivity and accuracy standards of the overall Admitting Department and units within the department.
16. Actively participates in staff meetings to integrate changes in procedures, new program requirements or training reviews of existing procedures. Updates and maintains own file of procedures, notices of changes, etc. so that related knowledge and skills are always current.
17. Works in all areas of the unit or department as assigned.
18. Willing to work flexible hours that includes weekends, overtime and other shifts as assigned.
19. Comply with Client Service Excellence and Patient Access department standards in interactions with patients, families, visitors and other staff.
20. Maintain proficiency and comply with all applicable infection control, health and safety policies and procedures as implemented by the department and/or work unit and the Medical Center.
21. Functions as a resource to other employees in the department.
22. Performs other duties as assigned by the Supervisor that include, but are not limited to: gathering data, maintaining statistical information, assisting with special projects.
23. Performs other duties as required.
OTHER FUNCTIONS AND RESPONSIBILITIES
Functions as a resource to other employees in the department.
Performs other duties as required.
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