Shire Jobs

Position Summary

The RN Insurance Authorization Specialist Team Lead obtains authorizations for all designated services at National Jewish Health. 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. This position will be responsible for completing accuracy review for clinical data recorded by both the LL intake LPNs and the RN Clinical Insurance Authorization Specialist team.

Essential Duties

Serves as point of contact for authorizations and authorization related clinical questions for Program Managed patients. 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 retroactive authorizations with medical staff, ancillary departments and insurance plans as necessary. Reviews and provides feedback to the UM Manager on the quality of LL intake forms quarterly for each of the LL intake LPNs. Reviews and provides clinical feedback to the UM Manager monthly on authorization quality for the team of RN clinical Insurance Authorization Specialist.

Competencies

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. Coaching and Teaching Others: Providing timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. 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. 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

None

Travel

None

Core Values

Be available to work as scheduled and report to work on time. Be will ng 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.

Minimum Qualifications

Education: Associate degree in nursing required, Bachelors of nursing, preferred. Work Experience: 3 years clinical nursing experience required. 2 years prior authorization experience, preferred. Special Training, Certification or Licensure: Active Colorado Registered Nurse License required. Certified Healthcare Access Associate (CHAA),