Authorization Integrity Specialist - Revenue Integrity & Denials Mgmt

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$35.69 - $46.63

Scheduled Weekly Hours:

40

Position Overview

Responsible for proactive authorization controls that protect claim readiness and revenue prior to billing. Performs both pre-service authorization verification and post-procedure pre-bill validation to ensure the authorization aligns with services actually performed. Works high-risk scheduled and procedural accounts (for example OR, Cath Lab, IR, advanced imaging, and other prior-auth-dependent services) and coordinates timely corrections with Central Scheduling, clinical departments, physician offices, and revenue cycle teams. This role is part of Revenue Integrity and collaborates with Denials, CDI, UR, HIM, and Patient Access.

MINIMUM REQUIREMENTS
Education:    High school diploma or equivalent. Registered Nurse (RN) license preferred. Certification or license in surgical or diagnostic procedures
Experience:    Three years' hospital revenue cycle, prior authorization, patient access financial clearance, or related experience. Experience working with payer portals and authorization documentation workflows required.. Experience with procedural/surgical authorizations and account-level pre-bill review preferred. Strong competency in procedural authorization validation and post-procedure pre-bill authorization reconciliation
Other Credentials:    
Knowledge and Skills:    Strong knowledge of payer authorization requirements, including CPT/HCPCS, units, date range, site of service, and level of care dependencies. Strong understanding of hospital claim flow and pre-bill controls. Strong analytical and detail orientation with ability to identify mismatches quickly. Effective communication skills for provider offices, clinical leaders, scheduling teams, and billing teams. Strong organizational and follow-through skills in high-volume environments.
Special Training:    Proficiency with EHR/revenue cycle platforms, payer portals, and authorization tools. Proficiency with Microsoft Excel and standard documentation/work queue tools.
Mental, Behavioral and Emotional Abilities:    Ability to function with minimal supervision and exercise sound judgment. Ability to collect, create and research complex or diverse information.
Usual Work Day:    8 Hours  
Reporting Relationships
Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS
Performs pre-service authorization integrity review for scheduled high-risk accounts to confirm authorization is present, valid, and aligned with planned services.
Verifies authorization elements including payer, CPT/HCPCS, diagnosis linkage (as applicable), units, date span, rendering/facility, and site/setting (inpatient/outpatient/observation).
Performs post-procedure pre-bill authorization validation by comparing final services performed/coded to authorization approvals and identifies mismatches prior to claim release.
Identifies and resolves variances such as missing authorization, incorrect CPT, wrong units, wrong site/setting, expired authorization, and add-on procedure gaps.
Initiates timely correction workflows with Central Scheduling, physician offices, and clinical departments; escalates unresolved high-risk accounts.
Applies hold/release standards for accounts with unresolved authorization risk before billing finalization.
Documents findings, actions, contacts, and final disposition in designated work queues/trackers using standard issue categories and closure criteria.
Communicates clearly with downstream billing/follow-up teams regarding account status and required next steps.
Supports retro-authorization and post-service correction workflows where permitted; routes non-correctable cases to the appropriate Denials team pathway after pre-bill controls are exhausted.
Tracks recurring defects and contributes to root-cause trending (for example scheduling workflow gaps, provider office process issues, payer rule changes, documentation timing issues).
Participates in daily/weekly huddles with Revenue Integrity and cross-functional partners to improve first-pass claim quality.
Maintains productivity, quality, and turnaround standards established by Revenue Integrity leadership.
Assists with onboarding, cross-training, and workflow documentation updates as requested.
Performs other duties as assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT
Frequent physical demands include: Sitting , Standing , Walking , Keyboard use/repetitive motion

Occasional physical demands include:

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Very Accurate 20/40, Near Vision, Accurate Far Vision, Minimal Color Discrimination, Minimal Depth Perception, Accurate Hearing
Anticipated Occupational Exposure Risks Include the following: N/A

IND123.

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.