Prior Authorization Specialist

Description

Position Summary: The Prior Authorization Specialist is responsible for obtaining pre-certification and pre-authorizations for procedures, surgeries, and tests, assists in scheduling appointments for both outpatient and inpatient surgeries at area hospitals or surgery centers, coordinates patient appointments/orders and ensures patients’ acknowledgment of their financial obligations outside of their insurance coverages. Full time- Monday-Friday 8am-5pm

Job Responsibilities:

• Contact insurance carriers to verify patient’s insurance eligibility, benefits and requirements
• Request, track and obtain pre-authorization from insurance carriers within time allotted for medical and services
• Request, follow up and secure prior authorizations prior to services being performed
• Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations
• Communicate any insurance changes or trends among team
• Maintains a level of productivity suitable for the department
• Clearly document all communications and contacts with providers and personnel in standardized documentation requirements, including proper format
• Work with various internal departments to ensure procedures, surgeries and tests are covered by patients’ insurance
• Speak with patients to determine how they can be assisted in receiving authorizations for their procedures and explains their financial exposures/liabilitie
• Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed
• Develop and implement prior authorization workflow, policies, and procedures
• Collaborate with other departments to assist in obtaining pre-authorizations in a cross-functional manner
• Review the accuracy and completeness of the information requested and ensure that all supporting documents are present
• Receive requests for pre-authorizations and ensure that they are properly and closely monitored
• Consult with secretaries, schedulers, providers, etc., to obtain clearance that treatment regimen is considered a medical necessity
• Process referrals and submit medical records to insurance carriers to expedite prior authorization processes
• Manage correspondence with insurance companies, physicians, specialists, and patients as required
• Create patients’ records and accounts and ensure that pre-authorization information is properly updated in them
• Secure patients’ demographics and medical information by using great discretion and ensuring that all procedures are in sync with HIPPA compliance and regulation
• Other duties as assigned

Qualifications

Experience: Previous medical office experience required. Surgical scheduling experience and familiarity with CPT and ICD-10 coding is highly desired. Must have excellent verbal and written communication skills. Requires effective customer relation skills, ability to organize and interpret data. Ability to work independently while communicating with several departments and external companies.  

The above statement reflects the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the job.