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Medical Authorization Specialist

DJO Surgical
United States, Texas, Dallas
December 18, 2022

Job Description:

We are seeking a dedicated individual with a background in healthcare reimbursement to join DJO as a Medical Authorization Specialist based out of our Lewisville, TX office. This role is responsible for seeking benefit coverage for patients from insurance groups with the responsibility of timely and compliant order entry, benefit verification and prompt follow up. This position works collaboratively with cross-functional internal and external teams to obtain necessary documentation required to obtain insurance authorizations. This is a great opportunity to join an evolving Revenue Cycle Management (RCM) Team dedicated to supporting our CMF Bone Growth Stimulator business!

JOB RESPONSIBILITIES

  • Answers inbound and outbound calls, researches, and identifies insurance to ensure compliant/proper account resolution.
  • Verifies insurance eligibility and follows coordination of benefits guidelines.
  • Faxes accurate and thorough Pre-Authorization Request Letters.
  • Determines revenue amounts based on allowable, benefits, unit price, payer guidelines, copayment, and contract pricing.
  • Submits appropriate and accurate billing to Government entities and private insurance payers consistent with Federal, State and insurance-specific requirements.
  • Pursues supporting documentation from Sales Team to ensure all required documents are received prior to invoicing.
  • Reviews prescriptions, Letters of Medical Necessity and/or Chart Notes to ensure both completeness and accuracy.
  • Ensures that orders meet criteria and compliance standards, and resolves assigned denials and variances by accurately determining the root cause and collaborating to reduce the denial or variance.
  • Works to resolve submission issues which can include obtaining the appropriate Medical Record documentation or validation of coding.
  • Reviews orders for accuracy and completeness prior to providing the "OK to Place" and invoicing.
  • Processes assigned correspondence and telephone inquiries from patients and payers in a compliant manner and promptly responds in writing or verbally.
  • Appropriately challenges insurance companies by communicating information on Medical Necessity and negotiating coverage and pricing for the purchase of DJO products that meet all applicable payor guidelines.
  • Serves as back-up for other PCS Representatives and their assigned region(s), as needed, to maintain timely turnaround time (TAT).
  • Builds and maintains professional relationships with Sales Team(s) based upon region assignments.
  • Supports Sales Team(s) by providing constant and accurate communication using online tools, email, and phone.
  • Communicates with Management and Payor Development regarding payer trends.
  • Communicates and escalates business concerns to Management when appropriate.
  • Actively participates in process improvements and develops strategies to ensure compliance and reduce claim edits by collaborating with management and other internal departments.
  • Maintains professional and technical knowledge by staying current on relevant products (both of DJO and its competitors), reviewing clinical publications/studies, and establishing personal networks.
  • Adheres to all internal Corporate Compliance guidelines, OIG and government health care regulations, and other payor policies.
  • Treats Protected Health Information (PHI) with the strictest confidentiality in accordance with HIPAA standards.
  • Other duties as assigned.

QUALIFICATIONS

  • High School Diploma or GED required.
  • Minimum of 3 years of experience with compliant patient billing, customer service, claims processing or related experience in a health care environment required.
  • Knowledge of ICD-10 coding, medical terminology, third party billing and collections, and managed care requirements required.
  • Proficiency in Microsoft Office applications required.
  • Strong attention to detail and passion for patient care and doing the right thing when decisions need to be made.
  • Must have full understanding of customer service and compliant insurance follow-up processes (i.e., Billing, Collections, Managed Care, Medicare, Medicaid, and Commercial payor practices).
  • Experience responding to patient and insurance inquiries preferred.
  • Experience using DataWorks, TIMS, or similar case management software strongly preferred.

TRAVEL

  • This position does not require travel.

WORK ENVIRONMENT & PHYSICAL DEMANDS

  • Typical office environment.
  • Physical Demands: May occasionally lift up to 10 pounds. Routinely uses standard office equipment such as computers, keyboard, phone, print. Required to talk and hear. Must be able to sit and stand for extended periods of time and use hands and fingers to handle or feel, and to manipulate keys on a keyboard and operate portable input devices (e.g., smart phone, mouse). May occasionally reach with hands and arms. Must have the ability to look at a computer screen for extended periods of time.
  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

ABOUT DJO GLOBAL
DJO Global is a leading global developer, manufacturer and distributor of high-quality medical devices that provide solutions for musculoskeletal health, vascular health and pain management. Our products address the continuum of patient care from injury prevention to rehabilitation after surgery, injury or from degenerative disease, enabling people to regain or maintain their natural motion. Our products are used by orthopedic specialists, spine surgeons, primary care physicians, pain management specialists, physical therapists, podiatrists, chiropractors, athletic trainers and other healthcare professionals. In addition, many of our medical devices and related accessories are used by athletes and patients for injury prevention and at-home physical therapy treatment. Product lines include rigid and soft orthopedic bracing, hot and cold therapy, bone growth stimulators, vascular therapy systems and compression garments, therapeutic shoes and inserts, electrical stimulators used for pain management and physical therapy products. Our surgical division offers a comprehensive suite of reconstructive joint products for the hip, knee and shoulder. Our products are marketed under a portfolio of brands including Aircast, Chattanooga, CMF, Compex, DonJoy, ProCare, Exos, Dr. Comfort, DonJoy Performance and DJO Surgical.

For additional information on the Company, please visit www.DJOglobal.com.

DJO is a growing subsidiary of diversified technology leader Colfax Corporation

EOE AA M/F/VET/Disability

All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of race, religion, color, national origin, sex, protected veteran status, disability, or any other basis protected by federal, state or local laws.

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