Clinical Authorization Specialist

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• Support the authorization department through utilization of clinical knowledge with associated treatments.
• Provides analysis of medical records to determine medical necessity in the clinical record and provides feedback to the providers and clinical team.
• Navigates high dollar treatments and provides additional clinical support as well as potential patient contact.

Minimum Qualifications

EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. High school graduate or equivalent. 2. Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC). EXPERIENCE: 1. Two (2) years of healthcare experience.

Preferred Qualifications

EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Associate or advanced degree. 2. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). CORE JOB DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned. 1. Reviews the medical record for clinical documentation in relation to ordered treatment. Provides education to providers in relation to insurance policy of any variances. 2. Provides coordination of high dollar services that would include analyzing the medical record for medical necessity and provides authorizations. Acts as a point of contact for assigned services that will interact with the clinical leaders in the department. 3. Researches each request including reviewing medical policy to ensure each requests is processed with minimum delay and risk of denial. 4. Effectively communicates clinical information with payor to obtain authorization for appropriate level of care and procedure, and documents interactions in patient’s electronic medical record (EMR). 5. Provides prompt follow up with the Payor to ensure current authorization and accurate payment for the patient’s stay/treatment. 6. Provides prompt feedback regarding payor determination to Supervisor/Clinic, enabling them to evaluate/redirect the current patient plan of care in order to streamline the delivery of service. 7. Identifies pre-services denials by third party payor and notifies Supervisor/Clinic for immediate intervention. 8. Proactively communicates any change in payor information and follows up with payor to ensure services are authorized. Documents all changes and all payor information (i.e. DOS, Service (CPT/HCPC codes), LOC, Reference #, Authorization #, contact and phone number, and website used) appropriately. 9. Based on assigned area, communicates with patient to obtain any and all information needed, scheduling, Charge Capture, verify and obtain referrals and pre-authorizations both for services provided within the hospital system and outside facilities. 10. Communicates with the patient in regards to insurance information needed, the anticipated self-pay portion including co-payments/deductibles/co-insurance. Provides available denial information and appeal options to the patient. 11. Completes assigned appeals for retro-authorizations focusing on medical necessity. Utilizes the physician documentation when appropriate to support services rendered 12. Notifies financial counseling of all patients with a high out of pocket. Refers self-pay patients with limited or exhausted benefits to financial counselors and/or social worker to determine eligibility. 13. Researches and resolves denials and communicates findings to department and/or Clinical Denial teams. 14. Maintains confidentiality/HIPPA according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information. 15. Reviews medical records and applies information to payor policies or LCD/NCD. Notifies treatment team of missing documentation pre-service. 16. Maintains assigned Work Queues in a timely and effective manner. 17. Participates in on-going educational activities to develop, maintain and enhance professional expertise as determined by leadership. PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Must be able to sit for extended periods of time. 2. Must have reading and comprehension ability. 3. Visual acuity must be within normal range. 4. Must be able to communicate effectively. 5. Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment. WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Office type environment. SKILLS AND ABILITIES: 1. Excellent oral and written communication skills. 2. Excellent customer service and telephone etiquette. 3. Must demonstrate the ability to use tact and diplomacy in dealing with others. 4. Knowledge of ICD9/CPT Coding or Medical Terminology. 5. Knowledge of third party reimbursement. Additional

Job Description

Scheduled Weekly Hours: 40 Shift: Exempt/Non-Exempt: United States of America (Non-Exempt) Company: WVUH West Virginia University Hospitals Cost Center: 403 WVUH Care Management Address: 1 Medical Center Drive Morgantown West Virginia Equal Opportunity Employer West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. Thank you for your interest in working for WVUM. Please explore our open opportunities in the list below and apply for any positions in which you would like to be considered. You'll be able to keep track of your progress on our site. The West Virginia University Health System is West Virginia’s largest health system and the state’s largest employer with more than 3,400 licensed beds, 4,600 providers, 35,000 employees, and $7 billion in total operating revenues. The Health System is comprised of 25 hospitals – including J.W. Ruby Memorial Hospital, an 880-bed academic medical center, and the 150-bed WVU Medicine Children’s Hospital in Morgantown, West Virginia – and five institutes. To learn more, visit WVUMedicine.org.