Capital Health (US)
About Capital Health
Capital Health is a leader in providing progressive and quality patient care in the region. With a strong focus on excellent nursing staff, physicians, and cutting-edge technology, Capital Health has earned recognition as a Magnet-Recognized health system for nursing excellence five times. We operate two hospitals and a network of primary and specialty care services through Capital Health Medical Group, which includes over 250 healthcare professionals.
Position Overview
The Call Center Authorization/Quality Specialist plays a critical role in ensuring that outpatient testing services are properly authorized and audited before they are rendered, optimizing reimbursement and minimizing denials. This position requires a detailed understanding of pre-registration, scheduling, and insurance verification procedures, ensuring all required documentation is accurate and complete for scheduled services.
As a Call Center Authorization/Quality Specialist, you will contribute directly to the quality of patient care and operational efficiency. This role requires someone who is attentive to detail, proactive, and able to work with insurance providers and medical teams to resolve issues and ensure compliance.
Key Responsibilities
Authorization & Auditing
- ✔ Verify Authorizations: Secure insurance authorizations and pre-certifications for outpatient services before they are rendered.
- ✔ Insurance Compliance: Ensure pre-certifications are verified to guarantee appropriate reimbursement.
- ✔ Chart Review: Perform chart reviews to ensure complete and accurate demographic, diagnosis, and insurance details.
- ✔ Address Discrepancies: Report discrepancies and work with relevant teams to resolve issues promptly, ensuring compliance with operational procedures.
Communication & Coordination
- ✔ Liaise with Physician Offices: Maintain effective communication with physician offices to obtain necessary information for authorizations and pre-certifications.
- ✔ Customer Interaction: Respond to patient inquiries regarding insurance, authorizations, and scheduling, maintaining a professional and helpful attitude.
- ✔ Team Collaboration: Work closely with other hospital staff, providers, and patients to resolve any issues related to authorizations and pre-registration.
Process Improvement
- ✔ Audit & Feedback: Review processes and make recommendations for improving authorization procedures, ensuring smoother operations.
- ✔ Training: Assist in the development and training of new staff members, ensuring they are competent in all aspects of the job.
- ✔ Quality Reporting: Report opportunities for quality improvements, both in revenue generation and reducing denials.
Compliance & Documentation
- ✔ Maintain Compliance: Stay up-to-date with insurance rules, regulations, and internal policies, ensuring all actions are compliant with industry standards.
- ✔ Document Competency: Ensure that all documentation and processes are thoroughly recorded and maintained for auditing purposes.
Required Qualifications & Skills
Education & Experience
- ✔ High School Diploma or GED is required.
- ✔ 5 years of experience in patient scheduling or a medical office role, working with insurance verification and authorization.
- ✔ Experience with insurance verification systems like Experian and Navinet is preferred.
Knowledge & Technical Skills
- ✔ Medical Insurance Knowledge: Understanding of insurance plans, pre-certifications, and billing procedures.
- ✔ Medical Terminology: Basic knowledge of medical terminology and diagnosis.
- ✔ Technical Proficiency: Comfortable using online portals, insurance applications, and pre-registration systems.
- ✔ Excellent Communication Skills: Ability to clearly communicate with patients, medical providers, and insurance companies.
Mental & Behavioral Abilities
- ✔ Problem Solving: Able to identify and resolve issues involving routine situations effectively.
- ✔ Attention to Detail: Maintain accuracy when reviewing charts, patient information, and insurance details.
- ✔ Multitasking: Ability to handle multiple tasks and meet deadlines in a fast-paced environment.
Physical Requirements & Work Environment
- ✔ Physical Demands: The role involves frequent sitting, standing, walking, and repetitive motion.
- ✔ Lifting Requirements: Occasional lifting of items weighing up to 15 lbs from the floor to waist height and 10 lbs at waist level or above.
- ✔ Sensory Requirements: Good vision (20/40), hearing, and minimal color discrimination.
Why Join Capital Health?
Capital Health offers an exciting and supportive work environment for professionals looking to grow in the healthcare industry. As a Call Center Authorization/Quality Specialist, you will contribute to ensuring high-quality patient care while working with a dynamic team. If you’re detail-oriented, experienced in insurance verification, and interested in contributing to a top-tier health system, this is the role for you.
Capital Health provides ongoing training and development, with opportunities for career growth within the organization. Join our dedicated team and make an impact on the lives of our patients!
How to Apply
If you’re looking to join a respected health system and contribute to our mission of providing quality patient care, apply today for the Call Center Authorization/Quality Specialist position at Capital Health.
Find similar jobs at: https://careerjunctionza.co.za/jobs/
TIPS for CV Related to This Post
- Highlight Relevant Experience: Make sure to list your experience in patient scheduling, insurance verification, and any roles involving medical office tasks.
- Demonstrate Technical Proficiency: Showcase your experience with insurance systems such as Experian, Navinet, or similar platforms.
- Focus on Soft Skills: Emphasize your communication, problem-solving, and attention to detail skills, which are crucial for this position.
- Certifications: If you have any certifications in medical billing, coding, or insurance, make sure to include them.
- Tailor Your CV: Focus on the specific qualifications and responsibilities mentioned in the job posting to make your CV stand out.
