Pre-Authorization Specialist

Pre-Authorization Specialist

The Pre-Authorization Specialist is a member of the Pre-Authorization Department who is responsible for verifying eligibility, obtaining insurance benefits, and ensuring pre-certification, authorization, and referral requirements are met prior to the delivery of outpatient and ancillary services. The Pre-Authorization Specialist provides detailed and timely communication to both payers and clinical partners in order to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patient's record. Other duties as assigned.

Duties include, but are not limited to the following:

• Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt.
• Successfully works with payers via electronic/telephonic and/or fax communications.
• Responsible for verification and investigation of pre-certification, predetermination, and referral requirements for services.
• Determines medical necessity by reviewing the appropriate medical policies established for each insurance payer.
• Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
• Communicates with patients, clinical navigators, financial counselors, and others as necessary to facilitate authorization process.
• Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals.
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in electronic medical record.
• Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements.
• 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.
• Operates standard office equipment (e.g. copier, personal computer, fax, etc.).
• Has regular and predictable attendance.
• Adheres to Advanced Pain Care's Policies and procedures.
• Performs other duties as assigned.

Requirements

Supervision: Pre-Authorization Manager

Minimum Qualifications:

Education: Requires a high school diploma or GED

Experience: Minimum of three years' experience in billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare, Medicaid, HMO's and PPO's required.

Working Conditions:

Environmental Conditions: Medical Office environment

Physical Conditions:

Must be able to work as scheduled – typically from 8:00 – 5:00 M-F

Must be able to sit for prolonged periods of time