Registration Representative/Preauthorization Representative

The Registration Representative/Preauthorization Representative is responsible for reviewing all DMH and Memorial Care scheduled inpatient and outpatient procedures, as well as outpatient diagnostic services. The goal is to ensure that each scheduled service meets all required insurance and clinical documentation standards prior to the service date.

Key Responsibilities:

• Authorization Verification:
  Review scheduled procedures and diagnostic services to confirm appropriate payor authorization is obtained and that the service aligns with the payor’s medical policies.

• Documentation Review:
  Validate the presence of a valid physician order and ensure all necessary clinical documentation requirements are met.

• Referral Coordination:
  Coordinate physician referrals for additional services, when deemed appropriate, to support patient care and continuity.

• Scheduling Support:
  Schedule and coordinate services as ordered by physicians, ensuring preauthorization is completed where required.

Skills & Qualifications:

• Knowledge of medical terminology, insurance preauthorization processes, and payor requirements.

• Ability to interpret and verify clinical documentation.

• Strong organizational and communication skills.

• Experience with electronic health records (EHR) and scheduling systems preferred.

Education and Experience Requirements:

• High school diploma or GED required.

• Previous experience in customer service required.

• Knowledge of medical service coding preferred.

• Familiarity with medical terminology or willingness to learn.

Environmental Factors:

• Work is performed in a standard office environment with minimal exposure to unpleasant, irritating, or hazardous conditions.

Physical Demands:

• Regularly required to sit, stand, and move through an office environment.

• The physical demands described here are representative of those that must be met to successfully perform the essential functions of the job.

Mental Demands:

• Must be able to work under stress and adapt to changing conditions.

• Must meet strict time deadlines and work efficiently under pressure.

• Ability to maintain strict confidentiality is essential.

Core Competencies and Skill Requirements:

Communication & Interpersonal Skills:

• Demonstrates excellent verbal and written communication skills.

• Maintains strong interpersonal relationships with coworkers, patients, and providers.

• Uses appropriate communication methods for different situations.

Organization & Attention to Detail:

• Able to organize work independently and manage time effectively.

• Strong attention to detail and accuracy is essential.

Technical Skills:

• Above average computer skills, including proficiency in Microsoft Word, Excel, and scheduling or preauthorization software applications.

General Skill Requirements:

• Adaptability:
  Adjusts well to change; handles competing demands and shifting priorities with professionalism; works under irregular schedules and occasional unscheduled overtime.

• Attendance & Punctuality:
  Arrives to work and appointments on time; keeps absences within acceptable guidelines; ensures responsibilities are covered during absences.

• Cooperation & Teamwork:
  Works well with others; maintains a positive attitude; demonstrates tact and consideration; assists coworkers as needed.

• Job Knowledge:
  Competent in job-specific knowledge; keeps current with industry developments; requires minimal supervision.

• Judgment & Decision-Making:
  Makes sound decisions in a timely manner; involves appropriate individuals in the decision-making process; respects confidentiality at all times.

• Problem Solving:
  Identifies issues proactively; analyzes situations; develops and implements effective solutions; collaborates in group problem-solving.

• Quality & Productivity:
  Demonstrates a commitment to accuracy and excellence; seeks feedback to improve performance; meets or exceeds productivity goals.

• Concentration:
  Maintains focus and accuracy for extended periods; stays alert to changing conditions or variations.

• Supervision:
  Capable of working independently or with minimal supervision; may train or review the work of others as necessary.

• Understands and applies payor-specific prior authorization requirements, staying up to date with policy and procedural changes from insurance providers.

• Serves as a liaison between hospital staff and physician offices, ensuring accurate communication of outpatient diagnostic service needs and referral information.

• Acts as a key contact for Utilization Review and Patient Financial Services, offering accurate and timely information as needed.

• Receives and coordinates pre-authorizations (including RQIs) for all outpatient services and schedules inpatient admissions as required.

• Coordinates physician referrals on appropriate patient accounts, ensuring additional services are authorized and scheduled as needed.

• Schedules, coordinates, and pre-authorizes all necessary services as ordered by physicians.

• Manages incoming phone calls professionally and efficiently to support departmental objectives and customer service expectations.

• Prioritizes scheduled patients in compliance with managed care preauthorization requirements and medical necessity protocols.

• Accurately documents all relevant case information using the account note function, including:

  • Telephone conversations

  • Consultations

  • Authorization details

  • Reference numbers

  • Case rationale

• Maintains a high level of customer service by following internal quality standards and confidentiality policies.

• Communicates regularly with case managers, physician offices, and nurses to secure necessary approvals and updates on patient accounts.

• Maintains accurate and current records of insurance and pre-authorization details.

• Identifies and communicates barriers to service or process improvement opportunities to management.

• Assists in the training of new personnel and supports implementation of new workflows or procedures.

• Performs other duties as assigned, contributing to the success and adaptability of the department.