Prior Auth Jobs in Delaware (NOW HIRING)

Nemours is seeking an Orthopedic Authorization Liaison to join our Nemours Children's Health team in Wilmington, DE.
The Orthopedic Authorization Liaison is responsible for optimizing payment of services by obtaining and processing Elective, Urgent, and Emergent referrals and authorizations for Orthopedic patients with non-participating insurance including but not limited to out-of-state Medicaid plans and commercial insurance plans. The Liaison is also responsible researching and notifying family of co-payment responsibilities. Referrals and authorizations are obtained prior to the date of service. During the referral process the Liaison will partner with the Primary Care Practitioner to obtained required referrals. The Liaison will be a leader in working with outside groups to educate around the referral/auth process. During the authorization and notification process the Liaison 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: Hospital and Physician Authorization departments, non-Nemours physician offices, managed care department, Nemours Physicians, and Departmental Administrative Staff to ensure that accurate information is collected and distributed effectively and efficiently. The Liaison utilizes daily reports and work queues to complete follow up on non-approved cases and assure completion prior to appointment or admission date according to department standards. In addition, the Liaison will report weekly on payor issues, barriers impacting workflows, and specific issues that could result in a non-reimbursable visit. The Liaison will have the ability to cover all referral and authorization types and demonstrate effective utilization of EPIC applications as indicated by performance measures. This position will also assist with educating the Orthopedic Surgical Coordinators and other clinical and non-clinical team members on high-level processes and act as a resource for the department.
Essential Functions

• Ensure timely notification and request for authorization/referrals is handled in accordance with policy and payor requirements.
• Maintaining confidentiality, verify patient demographics, insurance eligibility, benefits, and financial responsibility.
• Ability to request/obtain authorizations/referrals for Orthopedic patients with non-participating insurance.
• Contact families, primary care providers, and other allied health professionals to obtain necessary information and assist with insurance issues preventing authorization/referrals.
• Knowledge of participating and non-participating insurances, billing, Epic work queues, insurance authorization requirements, CPT and ICD-10 codes, managed care, utilization management, financial estimates, and medical terminology.
• Develop spreadsheets and databases to analyze data, track authorization and denial trends, and report patterns.
• Clearly document all communications and contacts with payors and families in standardized documentation requirements including proper format.
• Provides back-up to the Access Center Specialist role as needed.

Requirements
High School Diploma or equivalent required; Associate's Degree preferred
Certified Revenue Cycle Representative (CRCR) and/or Certified Healthcare Financial Professional (CHFP) is required
SuperUser certification is preferred
Minimum five years of referral and / or authorization experience is required.
About Us
Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.
Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.
Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.
Learn more at Nemours.org.