As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
1. 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
Ensure timely request for authorization is handled in accordance with departmental policy and payor requirements.
Ability of request and obtain preauthorization for assigned specialties and be able to cover for most specialties and conversions. Work departmental workqueues.
Through collaboration with Care Management, build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
Communicate effectively, timely and professionally in writing and verbally.
Contact and interview families in person or by phone contact to obtain necessary information and assist them with insurance issues that may be preventing authorization.
Prepare estimates for scheduled services.
Clearly document all communications and contacts with payors and families in standardized documentation requirements including proper format.
Record authorization information for all types of authorizations, complete standardized documentation requirements in expected format.
Consistently demonstrates excellent, empathetic and knowledgeable customer service skills to internal and external customers
Is aware and adheres to all State and Federal Regulations including, but not limited to: EMTALA, HIPAA, and the Joint Commission.
Authorization experience required.
High School Diploma required
1-3 years of job related experience required.
Schedule: Monday through Friday, 8:30 am to 5:00 pm
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Nemours is a pediatric health system of hospitals and specialty clinics serving children and families throughout the Delaware Valley and Florida. Our dedicated professionals integrate medical care, research, health education, and prevention to help improve the lives of children every day.