Prior Authorization Specialist

📋 Description

• • As a Prior Authorization Specialist at Shmueloff & Co. Law Offices, you will play a critical role in the seamless operation of our Revenue Cycle Department, ensuring that patients receive the necessary medical services without undue financial or administrative burden.
• • Your primary responsibility will be to meticulously obtain prior authorizations for a wide range of services, including surgical procedures, diagnostic testing, prescribed medications, durable medical equipment (DME), and outgoing referrals. This involves a deep dive into patient insurance plans and understanding the intricate clinical policies that govern authorization protocols for each health plan.
• • You will proactively identify all appointments and procedures requiring authorization by diligently monitoring schedules, system reports, and dashboards. This requires a keen eye for detail and the ability to anticipate needs before they become critical issues.
• • A core function of your role will be to accurately determine the referral and authorization requirements specific to each patient's insurance plan. You will leverage various online resources and adhere strictly to established department workflows to gather this essential information.
• • Demonstrating a comprehensive understanding of insurance carrier guidelines, clinical policies, and state-specific regulations pertaining to referrals and prior authorizations is paramount. This knowledge base will enable you to navigate complex requirements and ensure compliance.
• • You will be responsible for verifying patient insurance eligibility and benefits, ensuring that all information within the patient's account is accurate and up-to-date. This includes making necessary corrections and updates to reflect the most current insurance details.
• • Timely completion of referrals and prior authorizations, in strict accordance with department guidelines and workflows, is a key performance indicator. Your efficiency and accuracy directly impact patient care and the financial health of the practice.
• • Effective and clear communication is vital. You will engage with patients, physicians, office staff, and management to proactively resolve any issues that could lead to denied or delayed authorization requests. Building strong working relationships is essential for success.
• • You will develop and maintain complete system knowledge, enabling you to efficiently run reports, accurately document and manage referrals and authorizations, process correspondence, and resolve eligibility and authorization holds within your security access.
• • A critical aspect of your role involves the ability to request, prepare, and recognize the specific documentation required to substantiate the medical necessity for each service being authorized. This often involves collaborating with clinical staff to gather the right information.
• • You will provide immediate and constructive feedback to your supervisor and manager regarding any issues that impact workflow, reimbursement, or customer service. Your insights are valuable in driving continuous improvement.
• • Ensuring that all patient account information is entered accurately and appropriately is a non-negotiable aspect of the job, contributing to the integrity of our financial records.
• • You will respond in a timely manner and collaborate effectively with the Reimbursement Department teams. This partnership is crucial for minimizing claim denials and ensuring proper reimbursement for services rendered.
• • Working collaboratively with team members to meet department deadlines and benchmarks fosters a supportive and productive work environment. Teamwork is key to achieving our collective goals.
• • You will demonstrate proficiency in utilizing all available electronic tools and systems to organize and process your daily workload efficiently.
• • Anticipating and performing necessary job duties beyond the immediate scope demonstrates initiative and a commitment to the team's success.
• • Maintaining strict patient confidentiality in all aspects of your work is of utmost importance, adhering to all HIPAA regulations and company policies.
• • You will become an expert in selecting the correct insurance package within Epic, ensuring accurate billing and claims processing.
• • You will be adept at updating authorizations and claims to reflect the newly selected insurance package, maintaining data integrity.
• • You will master the art of sorting work queues and reports to efficiently identify and process daily tasks, including managing schedules and reviewing inbound and outgoing referral reports.
• • You will effectively move correspondence from the dashboard to the patient's account, ensuring all relevant documentation is captured.
• • You will develop a deep understanding of generally accepted insurance benefit terms and processes, enabling you to navigate complex scenarios.
• • You will excel in communication, crafting clear and concise case and authorization notations, and effectively liaising with physician and practice location staff, peers, supervisors, managers, and payers.
• • You will become proficient in requesting and preparing supporting documentation, such as medical records, dictation, and orders, to bolster authorization requests.
• • You will gain expertise in investigating authorization denials and appeals, working with both insurance providers and patients to resolve issues.
• • You will engage in patient financial counseling, including estimating out-of-pocket costs, searching for co-pay assistance or grants, discussing options with patients, and collaborating with providers on alternative medication solutions if necessary.
• • While the role is primarily remote, you may be required to travel to satellite locations for meetings, demonstrating flexibility and commitment.
• • This role offers a competitive hourly pay range of $21.58 to $26.98, with final salary determined by factors such as experience and location.