Prior Authorization & Eligibility

Description

We are seeking a detail-oriented and experienced Prior Authorization & Eligibility Specialist to join our dynamic Operations team. In this pivotal role, you will be responsible for ensuring the timely and accurate processing of prior authorizations and verifying patient eligibility for medical services. This position plays a critical part in facilitating patient access to necessary care, optimizing revenue cycles, and maintaining exceptional patient satisfaction. The ideal candidate will possess a strong understanding of healthcare insurance processes, excellent communication skills, and a meticulous approach to their work. You will collaborate closely with healthcare providers, insurance companies, and patients to streamline administrative procedures and resolve complex eligibility issues, contributing significantly to the smooth operation of our healthcare services.

Requirements

Demonstrated experience in a prior authorization or eligibility verification role within a healthcare setting. Proficiency in navigating various insurance portals and electronic health record (EHR) systems. Strong understanding of medical terminology, CPT codes, ICD-10 codes, and healthcare billing processes. Excellent organizational skills with a keen eye for detail and accuracy. Adept at problem-solving and critical thinking to resolve complex insurance-related issues.

Responsibilities

Verify patient insurance eligibility, benefits, and coverage for various medical procedures and services. Obtain and track prior authorizations from insurance carriers, ensuring all required documentation is submitted accurately and within established timelines. Communicate effectively with healthcare providers, patients, and insurance companies to facilitate information exchange and resolve eligibility or authorization discrepancies. Maintain meticulous records of all prior authorization requests, approvals, denials, and appeals in designated systems. Proactively identify and address potential issues related to patient eligibility or prior authorization requirements to prevent service delays or denials. Stay current with evolving insurance policies, regulations, and industry best practices related to prior authorizations and eligibility.

Qualifications

High school diploma or equivalent; associate's degree or relevant certification in healthcare administration or a related field is a plus. Proven ability to work independently and as part of a team in a fast-paced environment. Exceptional written and verbal communication skills, with the ability to convey complex information clearly and concisely. Commitment to maintaining patient confidentiality and adhering to HIPAA regulations.