Authorization Specialist in Gardena, CA at Pipeline Health Los Angeles

Date Posted: 7/14/2021

Job Snapshot

Job Description

Memorial Hospital of Gardena

Job Title: Authorization Specialist 

City: Gardena / State: California    

Case Management

Day Shift

From 8:00 AM

To 4:30 PM


Job Description and Job Responsibilites

Job Title: Authorization Specialist

Job Summary:

The position of the Authorization Specialist coordinates the utilization review and appeals process as part of the denial management initiatives. This position is responsible for coordinating phone calls, data entry and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals. Document and track all communication attempts with insurance providers and health plans. This position will follow up on all denials while working closely with the Corporate/Facility Utilization review teams, Business Office and Case Managers. This position will also serve as the primary contact and coordinate the work to maintain integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned.  This position will further support the department needs for Release of Information, discharge coordination or other duties as assigned.

This position supports the Pipeline Health Culture Club Values through the provision of distinctive and compassionate care to our employees and patients.

Essential Job Duties:

  • Maintain confidentially, protecting patient information at all times: minimum information necessary to those with right and need to know.
  • Coordinate all denials and appeal correspondence. Develop training and education for issues identified in RAC and authorization. Conducts oversight of all denial management functions. Follow all denials/ appeal activity to closure.
  • Maintains data base for tracking denials, reason, appeals, and outcome of appeals. Track status of all appeal activity using automated tracking system.
  • Verifies each page of the record is in the appropriately labeled folder by patient name, MRN, & volume number, in assuring a complete, legal medical record. Accurately accesses the completeness of the legal medical record
  • Collects, analyzes, aggregates, and presents data accurately.
  • Reviews medical records and other documentation to prepare Appeals packages.
  • Communicate and coordinate with various individuals/distributions and assist with the management of the day to day activities related to Government Audit Reviews, denials and appeals. Open communication between Corporate Team and Administration/ CFO, Business Office/ Financial Services, Case Management/ Physician Advisor. for clinical Review, RACs/ CMS
  • Collect/analyze, report status, metrics and trends of activity by different reviews from tool. Distribute reports on a routine basis to specific distribution group. Coordinate the RAC Committee with reports to Corporate compliance.
  • All Audits are to be kept in an organized retrievable way and also electronically scanned and filed.
  • Performs as a liaison, assisting medical staff members in accurate & timely chart completion through collaborative methods.
  • Assist with coordination of Gov't Review Audits (RAC) Committee activities and materials for committee meetings, including agenda, dashboards, analyses, reports, etc.
  • Responsible for the communication of all new policy's, memorandums and processes from department and/or governmental payers for all review audits.
  • Maintain integrity of Denials/Appeals database and assist in financial reporting of activity. Invoice submitted record requests, if applicable.
  • Responsible for review/analyze audits and insurance denial letters that are received and the validity of findings of various audit contractors.
  • In the event findings are incorrect, position responsible for communicating with audit contractors/insurance CM for correction and submitting evidence.
  • Develop Internal Training Programs. Other functions outside of RAC function such as clinical review, clerical/ administrative support for RAC tracking system data entry, Release of Information (ROI) process/ function.
  • Effective communication: writes and speaks clearly and concisely, affecting positive and efficient assistance to all requestors.
  • Perform required tasks and other duties as assigned, while maintaining a positive attitude.
  • Completes job duties in accordance with productivity requirements and quality standards.
  • Promptly report equipment malfunctions to the appropriate personnel to order service as needed.
  • Other Duties as assigned.

Job Requirements


  • High School Diploma or equivalent required. Associates degree or higher preferred.
  • Completion of a medical terminology course; preferred.
  • Background in business and office training preferred.
  • Minimum one year of denials management experience in acute care setting highly preferred