The Prior Authorization Specialist is responsible for multiple facets of patient financial account services within the facility; including but not limited to patient benefit assessment and insurance verification (pre-certification, authorizations, and determinations).

Supervisory Responsibilities:

• None.

Duties/Responsibilities:

• Collaborates with providers and office staff in ascertaining the appropriate authorization based on medical necessity and the treatment plan provided; communicates directly or indirectly with insurance companies.

• Requests authorization from various insurance companies by completing their assigned forms and/or accessing their website.

• Submits pertinent demographic and supporting clinical documentation with pre-authorization requests timely to avoid unnecessary delays in patient treatment.

• Contacts providers, patients, and insurance companies to obtain status and necessary information for pending requests.

• Appeals denials and/or set-up peer to peer reviews.

• Performs on-going check and balance system to ensure the integrity of the patient billing data and processes renewals for expiring authorizations.

• Ensures timely and accurate insurance authorizations for all CPT codes that will be charged during the course of the patient’s treatment before services are rendered. This ensures the organization will be reimbursed by the insurance companies when billed.

• Enters completed authorizations into electronic medical record.

• Maintains prior authorization tracking spreadsheet with clear, concise, and accurate documentation of all attempts and/or contacts made and received for accounts in accordance with company and client specifications.

• Provides updates to providers and clinic staff with authorization process information prior to the patient’s treatment.

• Maintains an approachable and appropriate attitude when interacting with all levels of personnel in a rapidly changing environment.

• Eagerness and ability to work independently as well as part of a team with flexibility and willingness to learn and take initiative on variety of tasks and projects.

• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.

• Follows departmental policies and procedures when necessary authorization is not obtained prior to service date.

• Answers provider, staff, and patient questions surrounding insurance authorization requirements.

Required Skills/Abilities:

• Must have good verbal and written communication skills to discuss billing with medical staff, HIM, patients, and the Collection department.

• Must have good problem-solving skills and attention to detail

• Must have good analytical and organizational skills

Education and Experience:

• High School Diploma or Equivalent required

• Experience in a hospital or physician practice preferred

• Minimum of 2 years experience in hospital billing/ pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare, Medicaid, HMO’s and preferred

• Experience in a business office position with a strong customer service background preferred

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.

• Must be able to lift up to 15 pounds at times.

This position is a Monday-Friday 8 am-4:30 pm position.