JOB SUMMARY:

Working under the direction of the Prior Authorization Manager, the Prior Authorization Specialist supports the business office by reviewing patient insurance information to determine if treatments, procedures, or medications require prior authorization and preparing and submitting requests to insurance companies with necessary documentation. Duties of this role include, but are not limited to:

• Manages and processes Prior Authorizations including, but not limited to, Medicare, Commercial, Medicaid, and Worker’s Compensation for injections, procedures, and other prior authorization needs.
• Identifies insurance coverage and coordinates with patients on their pre-procedure requirements.
• Maintains working knowledge of insurance prior authorization requirements, policies, and guidelines.
• Effectively communicates with insurance companies, physicians’ offices, outside vendors, and patients.
• Acts as a resource for providers in determining patient authorization needs.
• Manages and processes authorization denials and appeals.
• Processes prior authorization paperwork.
• Facilitates prior authorization projects and tracks metrics as required.
• Cross-trains on other duties as required.
• This position has no supervisory responsibilities.

QUALIFICATIONS:

• High School Diploma or GED required.
• Associate’s or Bachelor’s degree preferred.
• Minimum of 1-year of prior authorization experience required in healthcare environment.
• Medical terminology preferred (CPT/HCPCS, ICD-10 Codes, Procedures, etc.).
• NextGen experience preferred.

SKILLS & ABILITIES:

• Detailed oriented with ability to manage multiple priorities and work in a highly active environment.
• Strong verbal and written communication skills.
• Strong knowledge of insurance and eligibility.
• Ability to problem solve.
• Proficient computer and business skills.
• Self-directed, reliable, consistent.
• Ability to multi-task.
• Ability to work independently and with a team.
• Ability to be a professional representative of the company.
• Ability to follow directives as presented by your supervisor.
• Ability to follow company policies and procedures.
• Ability to abide by all HIPAA privacy laws.

• Manages and processes Prior Authorizations including, but not limited to, Medicare, Commercial, Medicaid, and Worker’s Compensation for injections, procedures, and other prior authorization needs.
• Identifies insurance coverage and coordinates with patients on their pre-procedure requirements.
• Maintains working knowledge of insurance prior authorization requirements, policies, and guidelines.
• Effectively communicates with insurance companies, physicians’ offices, outside vendors, and patients.
• Acts as a resource for providers in determining patient authorization needs.
• Manages and processes authorization denials and appeals.
• Processes prior authorization paperwork.
• Facilitates prior authorization projects and tracks metrics as required.
• Cross-trains on other duties as required.
• This position has no supervisory responsibilities