Prior Authorization Specialist

Job Summary:
The Prior Authorization Specialist is responsible for verifying insurance benefits and ensuring the appropriate pre-authorization process for medical procedures, tests, and treatments. This role plays a key part in facilitating patient care by working with insurance providers, medical professionals, and healthcare facilities to ensure coverage for necessary services. The specialist will handle both outpatient and inpatient scheduling, coordinating the entire process of obtaining authorization for specific exams, treatments, and procedures.

Key Responsibilities:

• Insurance Verification:

Verify and confirm insurance coverage for all patients, ensuring the necessary benefits are in place for required medical services. Work with patients, insurance companies, and healthcare providers to resolve discrepancies and ensure seamless billing processes.

• Prior Authorization Management:

Obtain prior authorizations for medical procedures, treatments, and imaging services by coordinating with insurance companies, healthcare providers, and third-party administrators. Ensure all required documentation and clinical information are provided in a timely manner to facilitate approvals.

• Communication with Insurance Providers:

Act as the primary point of contact between healthcare providers and insurance companies, ensuring proper communication regarding benefit coverage, requirements, and the status of authorization requests. Follow up on pending authorizations to expedite approvals.

• Coordination of Care:

Collaborate with physicians, clinical staff, and facility coordinators to ensure timely scheduling of procedures. Ensure that all necessary authorizations are in place before appointments are confirmed and that patients are informed of any authorization requirements.

• Documentation and Record-Keeping:

Maintain accurate records of authorization requests, approvals, denials, and any relevant communications. Ensure that patient and provider documentation is kept up to date for compliance with both internal policies and insurance regulations.

• Compliance and Policy Adherence:

Ensure all procedures are compliant with insurance regulations and healthcare industry standards. Stay up-to-date with changes in insurance requirements, medical coding, and authorization protocols to ensure the accuracy and timeliness of submissions.

• Problem Resolution and Appeals:

Assist in the resolution of denied authorizations and coordinate the appeals process if needed. Work closely with the billing department to address any billing discrepancies resulting from authorization denials.

• Patient Advocacy:

Serve as an advocate for patients, ensuring they have the necessary information and support to understand their insurance benefits and the prior authorization process. Help patients navigate potential barriers to care due to insurance constraints.

• Team Collaboration:

Work closely with other administrative, clinical, and financial teams to ensure a smooth flow of information and efficient processing of authorizations. Provide support and guidance to other staff members as needed.

• Performance Metrics:

Monitor and track the efficiency of authorization processes and work towards meeting departmental goals and key performance indicators (KPIs). Implement best practices to streamline the authorization process and reduce delays.

Skills & Qualifications:

• Knowledge of insurance verification and prior authorization processes, including working with various insurance providers.
• Strong understanding of medical terminology, procedures, and coding (CPT/ICD-10).
• Excellent communication skills, both verbal and written, with the ability to liaise effectively with insurance representatives, healthcare providers, and patients.
• Detail-oriented with strong organizational and multitasking abilities.
• Ability to navigate insurance portals and healthcare management systems.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook) and familiar with Electronic Health Records (EHR) software.
• Experience with medical billing and coding is a plus.
• Ability to work independently and as part of a team in a fast-paced environment.

Education & Experience:

• High school diploma or equivalent required; Associate's degree or relevant certification preferred.
• Minimum of 3 years of experience in healthcare administration, insurance verification, or prior authorization.
• Knowledge of HIPAA regulations and patient confidentiality requirements.

Job Type: Full-time

Pay: $ $26.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending