Coverage Determination Specialist

The Coverage Determination Specialist ensures that all information necessary for proper financial reimbursement for high-tech radiology services is analyzed and submitted to insurance companies for approval prior to the patient’s date of service. Collaborates with insurance companies and physician’s offices when necessary to verify eligibility and authorization requirements to ensure financial reimbursement for service.

• Promotes a positive patient experience by following required policies and procedures. Treats each patient as their most important priority.
• Provides professional, accurate, timely insurance verification and notification for high-tech radiology services.
• Verifies insurance eligibility, benefits and preauthorization/precertification/referral guidelines for the service scheduled or service being provided via website and/or calling the payor (Managed Care payors, Governmental payors and Commercial payors).
• Ensures all patient account activity is documented in the appropriate computer system timely and thoroughly.
• Validates that all necessary referrals, pre-certification and/or authorizations for scheduled service are accurately and thoroughly documented and are valid for the scheduled procedure being performed.
• Reviews medical necessity guidelines for scheduled studies when preauthorization or predetermination is unavailable by utilizing payor websites and documentation provided by the referring physician.
• Communicates and educates patients and physician practices to ensure compliance with identified payor requirements as needed.
• Reviews and resolves preauthorization/precertification/referral issues that are not valid and contacts insurance carriers to verify/validate requirements to ensure accuracy and avoid potential denial and contact ordering physician office if necessary to have authorization submitted.
• Notifies patient or referring physician’s office when uninsured or underinsured patients are identified and discuss options.
• Assists in verifying eligibility and authorization requirements for walk-in patients’ procedures.
• Manages incoming orders to the preauthorization fax line and determines appropriate action required.
• Handles phone calls from Schedulers, patients, and/or referring providers regarding preauthorization questions.
• Performs other tasks or special projects as assigned by management.

• Strong communication skills with demonstrated ability to express ideas and information clearly and concisely in a manner appropriate to the audience
• Demonstrated ability to interact with patients, families, staff, physicians, and all levels of employees
• Ability to be accountable for quality customer service and respond appropriately to a variety of personalities and situations
• Ability to maintain confidentiality, security and standards of ethics with all information
• Strong discretion in dealing with confidential and sensitive information
• Comply with all state/federal regulations (including HIPAA), company policies, standards and health & safety rules
• Ability to take initiative, be self-motivated and an independent, accountable, dependable performer
• Demonstrated critical thinking, problem analysis and problem resolution skills
• Ability to set priorities, be flexible and manage multiple tasks simultaneously
• Ability to work effectively in a high volume, fast-paced environment
• Ability to perform work accurately and thoroughly
• Ability to use and understand medical terminology
• Proficiency with Electronic Medical Records (EMR) and Microsoft Office Word and Excel
• Regularly and consistently demonstrates commitment to organization values

• High School diploma or equivalent
• 1 - 2 years' medical pre-authorization experience preferred
• 1 - 2 years’ scheduling or medical office experience desired or equivalent combination of education and experience
• Prior experience with medical billing, Medicare and private payors preferred
• Prior experience with CPT, HCPCS and ICD-9 codes preferred