Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full-time remote Authorization Specialist to join our Solutions 4 Community Health team.

Responsible for screening requests for prior-authorization. Obtains Authorizations from various insurance plans under the supervision of the Director of Managed Care according to departmental guidelines. Review and analyze claim denials and reach out to payers in a attempt to settle patient accounts. Assist with claim issues, including preparing coding appeals. Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery.

Essential Duties and Responsibilities for a Authorization Specialist:

· Prioritizes incoming Prior Authorization requests.

· Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines.

· Refers any managed care requests that need additional clinical information to ADHC Service Provider, Primary Care providder or Program Director.

· Verifies member eligibility via epaces and saves information in Managed Care repository.

· Identifies and informs managed care department and care providers of any insurance service changes and or benefits available to member.

· Informs care provider and Managed Care Department of authorization decisions made by managed care plan per department procedures.

· Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.

· Works with billing team, ADHC providers and key departments to promote an understanding of Prior Authorization requirements and processes.

· Supports managed care department in following up on request for Authorization or denial notifications.

· Tactfully handle telephone and email communications with Sun River Health Staff, and Outside Manage Care Organizations

· Clerical tasks will include but are not limited to data entry, faxing, filing, mailing and report distribution.

· Assit with various projects as needed utilizing agency software and Microsoft applications including Excel, Word and Outlook.

· Assists billing/finace team with various claim related tasks which may include but is not limited to: Appeals, claim reconciliation and payment postings.

· Reduces accounts receivable by reviewing and addressing claims with outstanding balances.

Minimum Qualifications: Active CPC Certification via AAPC.

Minimum Education Requirement: High school diploma, Associate's Degree preferred.

Minimum Work Related Experience: 1 year office experience.