QUALIFICATIONS :

• High School diploma or GED with Two Years of College or Professional School preferred
• Two years of experience working in the medical field
• Familiarity with Electronic Medical Record required
• Knowledge of online resources to obtain prior-authorizations
• One year experience with ICD-9 and current with ICD-10, CPT codes.
• Demonstrates overall knowledge of managed care plans
• Comprehensive working knowledge of third party insurance processes required
• Intermediate to expert knowledge and computer skills including Windows programs and database applications preferred. Includes good keyboard skills 45 wpm with high accuracy rate
• Understanding of insurance payor reimbursement, authorization, practice management systems follow-up helpful
• Ability to prioritize tasks, work independently, and in a close environment with peers
• Strong leadership skills with attention to detail and accuracy
• Ability to communicate effectively

JOB SUMMARY :

The Prior Authorization Specialist ensures necessary approvals obtained from insurance providers before medical procedures or services are rendered.

Responsibilities include : Verifying patient illegibility, reviewing medical documentation, communicating with healthcare providers & insurance companies to facilitate the authorization process.

Strong attention to detail & knowledge of insurance policies & procedures are essential to this role.

• Position Responsibilities / Duties :
• Contact insurance carriers to verify patient's insurance eligibility, benefits and requirements.
• Request, track and obtain prior-authorization from insurance carriers within time allotted for outpatient imaging, surgery and lab services
• Request, follow up and secure prior-authorizations prior to services being performed
• Works in collaboration with medical sites to obtain any additional clinical documentation that can be forwarded to insurance carrier
• Provides direct support to primary care practices and specialty care providers regarding utilization, authorization, and referral activities
• Proficient in the use of ICD-9 and CPT codes. (ICD-10 preferred)
• 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

Last updated : 2024-05-01