Pre-Authorization and Insurance Specialist

Purpose: The Pre-Authorization and Insurance Specialist is responsible for verifying insurance eligibility, benefits, and treatment history as well as processing and coordinating all referrals and coverage determinations for dental procedures. This specialist serves as a key liaison between dental providers, dental assistants, billing staff, patients and insurance entities to facilitate timely and accurate treatment requests. Duties include a variety of administrative and clerical tasks such as corresponding with insurance entities via phone, email, or mail; scheduling or rescheduling appointments and reviewing treatment plans for coverage and frequency limitations. 

1.    Reviews treatment plans, diagnostic codes, and treatment history before submission.
2.    Verifies insurance eligibility, benefits and frequency limitations before submission and scheduling of upcoming procedures.
3.    Accurately selects insurance plans in the Electronic Health Record (EHR).
4.    Reviews the requesting providers credentialing status per service location before submission.
5.    Ensures all dental notes and required documentation is complete and submitted to insurance entities in a timely manner.
6.    Prepares and submits referrals, prior authorizations, pretreatment estimates, precertifications or predetermination requests to insurance entities and collaborating facilities, ensuring all required information and attachments are accurate and complete.
7.    Contacts insurance entities to confirm approval requirements have been met and forwards determination details to the requesting location and provider.
8.    Schedules STAT, URGENT, and High-Risk referrals ensuring timely follow-up and documentation.
9.    Reschedules cancelled, missed, or no-show appointments.
10.    Monitors, tracks, and updates requests and expirations to prevent gaps in coverage or delays in care.
11.    Maintains accurate and up-to-date records of all determinations in a tracking log and the EHR system.
12.    Follows up on denials and appeal submissions in coordination with billing staff.
13.    Identifies and resolves discrepancies and problems as they arise.
14.    Contacts patients regarding their insurance determination and ensures they understand their treatment plan and benefits.
15.    Collaborates and communicates effectively with providers, dental assistants, billing staff, and other department staff to ensure authorization requirements are met and properly documented.
16.    Responds promptly to incoming calls and voicemails regarding pending determinations or benefit inquiries.
17.    Prepares forms for provider review and signature.
18.    Documents detailed determination status in the EHR (IDentalSoft, Athena or EPIC).
19.    Utilizes the EHR system(s) as the official medical record, following established documentation standards and maintaining patient confidentiality of Protected Health Information in accordance with HIPAA.
20.    Adheres to Western Wayne Family Health Centers (WWFHC) policies and procedures.
21.    Demonstrates strong interpersonal and time management skills.
22.    Cross-trains with front desk and billing teams to ensure complete understanding of related workflows and the ability to serve as back up when needed.
23.    Performs additional functions as determined and directed by dental or management staff.

1.    High School Diploma.
2.    Two (2) years' experience in a dental support role, or certified dental biller, pre-authorization specialist, or insurance coordinator role in a healthcare setting.

1.    Knowledge of insurance verification and authorization processes for dental services
2.    Understanding of payer guidelines and frequency limitations
3.    Strong analytical skills to review benefit coverage and identify payer-specific requirements.
4.    Proficiency creating, using, and maintaining electronic health records
5.    Ability to communicate effectively with patients and staff to resolve insurance-related issues.
6.    Ability to develop and effectively maintain relationships with vendors/providers
7.    Must demonstrate and competently understand the sensitivity and confidentiality status of the patients’ information
8.    Must demonstrate an understanding of medical terminology
9.    Must possess valid driver’s license
10.    Must adhere to the Confidentiality and HIPAA policies
11.    Skilled with working in a complex work environment
12.    Ability to maintain confidentiality at all times and maintain organizationally appropriate relationships
13.    Knowledge of organization policies and procedures
14.    Knowledge of computers, systems, and applications
15.    Skilled in exercising initiative, appropriate judgment, problem-solving and decision making
16.    Skilled in developing and maintaining effective relationships with patients, customers, and other staff