Insurance Follow-Up Specialist

Job Description

JOB SUMMARY

The Prior Authorization Specialist is responsible for working with third party payers and providers to ensuring physician services that require pre-authorizations are completed in an accurate and timely manner. Responsible for ensuring payment of tests and procedures prior to administration of test and/or procedure. Must also performing insurance and benefit verification as a part of obtaining prior authorizations for services provided to patients.

JOB RESPONSIBILITIES

•Review, evaluate, verify and process assigned clinic pre-certification requests for Inpatient, Outpatient and other clinic procedures performed by facility providers.

•Contact insurance companies for pre-certification, at least seven days prior to the patient's scheduled procedure.

•Apply basic coding knowledge and proficiency in medical terminology to translate orders to appropriate CPT and Diagnosis information required to provide to third party payers for prior authorization.

•Work with providers to coordinate peer-to-peer review with third party payers or find suitable alternatives to tests or procedures that do not meet prior authorization requirements.

•Work with third party payers to obtain all necessary information to complete a prior authorization, such as reviewing medical document for past procedures, therapies, tests or other clinical services.

•Enter all prior authorization information into the scheduling and billing system.

•Assist Clinics in obtaining prior authorizations for emergency admits and for patients needing same day clinic visit/hospital admit/procedure.

•Confirm all necessary information needed to properly perform and identify billing information needed to maintain compliance with institutional, state and federal practices.

•Verify patient eligibility and prior authorization requirements through On-line verification software or by telephone and follow up with third party payers within 0-48 hours of request.

•Maintain open line of communication with clinic personnel.

•Assists in training new employees of the prior authorizations team.

•Provide Team Coverage.

•Performs other tasks as assigned by supervisor.

MINIMUM EDUCATION & EXPERIENCE

•High school diploma or GED required; college preparation preferred.

•2-5 years’ experience in a healthcare prior authorization or insurance authorization role.

•Basic coding knowledge, understanding of CPT and ICD-10, and proficiency in medical terminology.

KNOWLEDGE, SKILLS, & ABILITIES

•Thorough knowledge of the healthcare revenue cycle including ICD-9 and CPT coding, and CMS guidelines

•Working knowledge of electronic health records and practice management systems

•Knowledge of current payer precertification processes and guidelines

•Ability to multi-task and function effectively in a dynamic and fast-paced environment