Insurance Verification and Authorization Specialist

Insurance Verification And Authorization Specialist

Optima Dermatology is recruiting a full-time Insurance Verification & Authorization Specialist to join our Practice Support Center, based in Portsmouth, NH.

Reporting directly to the EDI Manager, the Insurance Verification & Authorization Specialist ensures accurate and timely verification of patient insurance eligibility and benefits, obtains prior authorizations for services requiring pre-authorization, and supports superior patient experience through proactive communication and collaboration. The Specialist reviews and updates patient insurance data for accuracy, investigates referral requirements, and partners closely with medical reception, RCM, and other internal teams to enable clean claims and reduce avoidable denials. Strong communication skills, critical thinking, and empathy are essential.

Responsibilities:

• Verify insurance benefits for patients prior to the appointment date.
• Obtain prior authorizations for services requiring pre-authorization prior to the patient's appointment.
• Review patient accounts for insurance accuracy and update any data as needed to ensure insurance and benefit level information are correct in the patient's account.
• Investigate referral requirements with insurers and patients as needed.
• Act as the subject-matter expert in patient insurance eligibility, verification, and benefit information.
• Support medical receptionists and other internal teams, including RCM, to facilitate accurate insurance/benefit collection and superior patient experience.
• Notate all insurance benefits and eligibility information in applicable Optima business systems.
• Perform eligibility and benefits checks prior to patient appointments as defined by SOP and quality standards.
• Create patient out-of-pocket estimates based on coverage levels and benefit guidelines and notate applicable business systems.
• Assist field operations with verifying demographics, insurance details, pharmacy, and patient preferences during pre-registration.
• Assist field operations with insurance referral interactions and questions.
• Address patient questions related to coverage and financial responsibility to streamline the experience and reduce surprises as needed.
• Maintain accurate patient information within confidential patient accounts and electronic records in accordance with HIPAA.
• Work assigned intra- and inter-departmental inquiries within defined SLAs and escalate priority issues appropriately.
• Demonstrate Optima's values in all interactions with empathy, positive intent, and professionalism.

Key Performance Indicators (KPIs):

• Eligibility/benefit accuracy: ≥ 98%.
• Denials due to eligibility/prior authorization: ≤ 2%.
• Turnaround times for eligibility and prior authorization: completed 24 hours to 2 weeks prior to appointment date (per payer requirements and internal SOP).
• Documentation: 99% of eligibility/benefit and authorization notes recorded in applicable business systems.
• Response time to internal/external inquiries: 24–48 business hours.

Qualifications:

• High school diploma or equivalent; coursework in business administration and/or accounting preferred.
• Minimum of five (5) years of healthcare reimbursement, patient access, or related experience preferred.
• Working knowledge of medical and insurance terminology; ability to interpret eligibility/benefit information and explanations of benefits (EOBs).
• Understanding of professional claims and common billing workflows.
• Outstanding communication skills with the ability to build rapport, actively listen, and educate patients and internal partners.
• Demonstrated problem-solving skills, attention to detail, and ability to prioritize and follow through in a fast-paced environment.
• Ability to work independently and as a collaborative team member across a distributed organization.
• Commitment to confidentiality and compliance with HIPAA and organizational policies.

About Optima Dermatology:

At Optima Dermatology, our mission to revolutionize skin care is made possible by our world-class team that is highly engaged, mission-driven, and inspired to set the new standard in dermatology. We foster a collaborative environment that is fun and hardworking, and we're excited to welcome team members who want to make a difference in the lives of our patients. This is a hybrid role, requiring one in-office day (Wednesday preferred).