Overview

Responsible for coordinating with insurance providers for verification, pre-certification, pre-authorizations, and pre-determination for medical procedures within respective or designated service lines in the ARH System.

Completes benefits review and prior authorizations as required by all payers for scheduled services. The Preauthorization Coordinator interfaces with clinical staff, payer representatives, and patients, daily, to review scheduled services and to ensure complete and accurate information is documented.

This role completes necessary clinical review for prior authorizations as required by governmental and commercial payers, satisfying maximum net revenues and minimum avoidable losses for authorizations.

Responsibilities

• Ensures that patient demographic, insurance information, verification and eligibility have been established and documented.
• Verifies pre-certifications and obtains upgrades if needed
• Coordinates rescheduling in the event that prior-authorization is not obtained the day before scheduled treatment or diagnostics
• Obtains financial clearance.
• Verifies patient insurance eligibility and obtains necessary pre-authorization numbers, if required, prior to appointment date.
• Documents and communicates with clinical staff, physicians, administrators, and patients regarding insurance problems and / or discrepancies, and ensures all insurance information is current.
• Assists with denied claims
• Enters documentation and authorizations and pre-certifications in the EMR.
• Initiates and prepares correspondence as needed.
• Attends all mandatory workshops, seminars, or trainings as assigned by administrative personnel; ensures knowledge is up to date in an ever-changing environment.
• Obtains necessary clinical information needed to complete the prior-authorization.
• Schedules authorized services.

Qualifications

Education

Associate degree or equivalent experience preferred.

Minimum Work Experience

One-year minimum experience working with insurance pre-certification, billing, and coding preferred.

Required Skills, Knowledge, and Abilities

Knowledge : Current Procedural Terminology (CPT), Internal Classification of Diseases (ICD), Medical Terminology, EMR / HER, Insurance appeals, denials, and auto-posting process.

Explanation of Benefits (EOB), Current Regulatory Guidelines and Requirements.

Skills : Organizational, Verbal and Written Communication, Detail Oriented, Analytical and Problem Solving, Office Software Applications.

Last updated : 2024-05-31