Description

Job description

The Surgical Authorization Specialist is responsible for verifying eligibility, obtaining insurance benefits, and ensuring pre-certification, authorization, and referral requirements are met prior to rendering surgical services. The Surgical Authorization Specialist provides detailed and timely communication to both payers and fellow team members in order to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patient's record.

Main functions of the role are the following:

• Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to rendering services.
• Successfully works with payers in all forms of communications.
• Responsible for verification and investigation of pre-certification, predetermination, and referral requirements for services.
• Determines medical necessity by reviewing the appropriate medical policies established for each insurance payer.
• Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
• Continuous monitoring of pending documents for final determination.
• Peer to Peer evaluations
• Works with clinical team to discuss alternative treatment plans if services are denied.
• Communicates with patients, clinical navigators, revenue cycle team, surgery schedulers and others as necessary to facilitate authorization process.
• Other duties deemed necessary

Qualifications

• Required: High school diploma.
• 1-2 years in customer service oriented environment preferred.
• 1-2 years working within the insurance industry in a provider’s office, insurance company, or company where you were involved with employee benefits is preferred.
• Ability to work independently, give attention to detail, prioritize and perform several tasks together without losing concentration.
• Knowledge of insurance cards, medical insurance terminology, medical benefits, and CPT and ICD 9/10 coding.
• Must be able to follow established procedures.
• Excellent typing and computer usage skills, including Microsoft Word and Excel proficiency.
• Must possess good oral and written (English) communication skills.
• Must be well organized and detail-oriented.