The Pre-Authorization specialist will assist the Orthopedic & Sports Institute in obtaining prior authorizations for patient surgical and non-surgical procedures.
This position is responsible for verifying eligibility, obtaining insurance benefits, and ensuring pre-certification, authorization, and referral requirements are met prior to the delivery of inpatient, outpatient, and ancillary services.
This individual determines which patient services have third party payer requirements and is responsible for obtaining the necessary authorizations for care.
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 patients record.
Responsibilities & Duties:
Gather patient insurance benefit information through online portals and/or telephone.
Obtain prior authorization from insurance and document in patient charts on electronic medical records.
Ensure timely and accurate insurance authorizations are in place prior to services being rendered.
Communicate regularly with provider teams to ensure processes are followed and patient experience is industry best.
Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
Maintain a professional environment.
Always uphold confidentiality and HIPAA compliance and report violations to the Privacy Officer.
Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for patients.
Follows up with physician offices, financial counselors, patients and third-party payers to complete the pre-certification process.
Collaborates with internal departments to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.
Educates patients, staff and providers regarding authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.
Ensures all services have prior authorizations and updates patients on their preauthorization status.
Coordinates peer to peer review if required by insurance.
Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization.
Previous experience working in billing/prior authorization
Previous experience working with modern medical office practices
Previous experience working with Microsoft Excel
Communicating clearly and concisely, orally and in writing
Ability to communicate with staff and providers, both in person and over the telephone, in a tactful manner and under difficult situations
Detail oriented
Exceptional customer relations skills required.
Knowledge of online insurance eligibility systems.
Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.
Strong analytical, prioritization and organizational skills.
Exceptional communication and interpersonal skills with a high degree of diplomacy and tact.
Ability to effectively communicate with a variety of people under stressful circumstances.
Understanding of basic human anatomy, medical terminology and procedures for application in the patient referral / pre-certification / authorization processes.
Knowledge of third-party payers and pre-authorization requirements.
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