Insurance Authorization Specialist

Job Description:

GENERAL SUMMARY 

The Insurance Authorization Specialist handles all aspects of securing insurance authorizations for Urology services and procedures. This position will complete verification and prior authorizations of services, evaluate portion to be paid by the customer, and perform other insurance related assignments as directed.  

ESSENTIAL JOB FUNCTION/COMPETENCIES

Responsibilities include but are not limited to:

• Submits requests for insurance eligibility and prior authorizations for all required insurances based upon plan or insurance contract for all upcoming appointments at designated intervals.
• Secures a referral or order from the physician, if necessary.
• Documents information in Practice Management (PM) system to include policy and group number, patient demographics, copays/deductibles, and coinsurance.
• Maintains and updates internal listing of insurance carriers that require authorization.
• Runs account audits to ensure that authorization is being obtained where needed.
• Obtains information about patient insurance coverage, benefits, and eligibility.
• Verifies medical necessity in accordance with Centers for Medicare & Medicaid Services (CMS) standards and communicate relevant coverage/eligibility.
• Identifies patients who may need Medicare Advance Beneficiary Notices of Noncoverage (ABNs).
• Assists Business Office team with obtaining retro-authorizations.
• Coordinates with Call Center and Offices on prior authorization and eligibility activity as needed.
• Follows appropriate escalation procedures related to authorizations not obtained and contacts stakeholders when there is a threat to payment.
• Performs other position related duties as assigned.

CERTIFICATIONS, LICENSURES OR REGISTRY REQUIREMENTS

• N/A

KNOWLEDGE | SKILLS | ABILITIES

• Demonstrates understanding of business and how actions contribute to company performance.
• Demonstrates excellent customer service skills.
• Comprehensive understanding of insurance verification, contract benefits and medical terminology.
• Ability to follow policies and procedures and enter data into various electronic systems while maintaining the integrity and accuracy of the data.
• Professional verbal and written communication skills.
• Working knowledge of government and private payer billing regulations.
• Knowledge of EHR (Electronic Health Record), practice management software systems and Microsoft Office products.
• Ability to handle multiple tasks while meeting departmental deadlines.
• Ability to utilize multiple modes of communication (e.g., phone, fax, patient portal, e-mail, physician portal, mail, etc.) in a professional, accurate, efficient, and courteous manner.
• Knowledge of medical terminology, healthcare coding systems, and clinics functions.
• Excellent organizational skills and attention to detail.
• Customer-oriented with ability to remain calm in difficult situations.
• Delivers exceptional patient service throughout all interactions.
• Strong analytical and problem-solving skills.
• Skill in using computer programs and applications including Microsoft Office.
• Ability to build relationships with patients and display empathy and compassion to patients.
• Ability to work independently and manage deadlines.
• Complies with HIPAA regulations for patient confidentiality.
• Complies with all health and safety policies of the organization.
• Knowledge of governmental regulations and compliance requirements.
• Knowledge of Medicare, Medicaid, managed care, and other third-party payer’s guidelines.

EDUCATION REQUIREMENTS

High School Diploma or equivalent required.

EXPERIENCE REQUIREMENTS

2+ years experience working medical authorizations.

Comprehensive understanding of insurance verification, contract benefits, and medical terminology.

REQUIRED TRAVEL

N/A

PHYSICAL DEMANDS

Carrying Weight

Frequency

1-25 lbs.

Frequent from 34% to 66%

26-50 lbs.

Occasionally from 2% to 33%

Pushing/Pulling

Frequency

1-25 lbs.

Seldom, up to 2%

100 + lbs.

Seldom, up to 2%

Lifting - Height, Weight

Frequency

Floor to Chest, 1 -25 lbs.

Occasional: from 2% to 33%

Floor to Chest, 26-50 lbs.

Seldom: up to 2%

Floor to Waist, 1-25 lbs.

Occasional: from 2% to 33%

Floor to Waist, 26-50 lbs.

Seldom: up to 2%