Medical, Clinical & VeterinaryClinical Support & Patient Administration
About the job
Requirements
High school diploma or GED equivalent with five years of prior authorization experience, or a bachelor's degree with two years of prior authorization experience.
Three years of experience processing insurance requests to obtain prior authorization.
Experience and familiarity with insurance portals, including Anthem, Availity, Evicore, CoverMyMeds, and Magellan.
Proficiency with Microsoft applications and internet-based programs.
Ability to critically think, solve problems, and make independent decisions supporting the authorization process, including interactions with payer representatives, physicians, and hospital case managers.
Responsibilities
Obtain and process prior authorization requests; coordinate phone calls; enter and track data from insurance providers and health plans regarding authorization, expedited reviews, and appeals.
Document and track communication attempts with insurance providers and health plans, follow up on denials, and work to ensure services are validated.
Review accounts and initiate pre-authorizations and other managed-care requirements, routing them to appropriate departments as needed.
Collect demographic, insurance, and clinical information to ensure reimbursement requirements are met.
Notify necessary parties within required timeframes for routine and urgent service requests.
Assist in monitoring utilization services to support cost-effective use of medical resources through processing prior authorizations.
Communicate with patients and referring physicians about non-covered benefits or procedure coverage issues.
Assist with medical-necessity documentation to expedite approvals and ensure appropriate follow-up.
Provide consistent and comprehensive information, in writing and verbally, to facilitate approvals.
Ensure insurance-carrier documentation requirements are met and authorization documentation is entered and recorded in patient records.
Appeal pre-authorization denials and set up peer-to-peer reviews.
Maintain working knowledge of insurance companies and billing authorization requirements.
Identify and report undesirable trends, reimbursement modeling errors, or underlying causes of incorrect payment; review allowed variances from third-party payers.
Build and maintain working relationships with staff, referral sources, insurance companies, and medical providers.
Desired Qualifications
Knowledge and experience with payer processes to submit appropriate clinical documentation.
Experience using medical terminology.
Strong interpersonal skills to establish working relationships.
Verbal and written communication skills to communicate with staff at all levels and a patient population composed of diverse cultures and age groups.
Time-management skills to prioritize assignments and meet designated deadlines.
Ability to anticipate, recognize, and meet the needs of patients and their families.
Ability to work in a team-based environment to accomplish goals and objectives.
Ability to demonstrate respect and sensitivity for cultural diversity in the client’s workforce and patient population.
Keystone Advisors is looking for a Prior Authorization Specialist to join our team in Matteson, IL supporting one of our healthcare clients.
This is a Hybrid position.
Job Summary
The Prior Authorization Specialist is responsible for obtaining and processing all prior authorization requests, coordinating phone calls, entering and tracking data from insurance providers and health plans regarding authorization, expedited reviews, and appeals. The Prior Authorization Specialist is required to document and track all communication attempts with insurance providers and health plans, follow up on all denials while working to ensure services are validated.
Typical Duties
Reviews accounts, and initiate pre-authorizations, and other requirements related to managed care; route to appropriate departments as needed.
Collects demographic, insurance, and clinical information to ensure that all reimbursement requirements are met.
Notifies the necessary parties within the required timeframe for routine and urgent requests for services.
Assists in monitoring utilization services to assure cost effective use of medical resources through processing prior authorizations.
Communicates with patients and/or referring physicians on non-covered benefits or procedure coverage issues.
Assists with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
Provides consistent and comprehensive information (both in writing and verbally) to facilitate approvals.
Ensures insurance carrier documentation requirements are met and authorization documentation is entered and recorded in the patient’s records.
Appeals pre-authorization denials and/or set-up peer to peer reviews.
Maintains an extensive working knowledge and expertise of insurance companies and billing authorization requirements.
Identifies and reports undesirable trends and reimbursement modeling errors or underlying causes of incorrect payment; review allowed variances from third party payers.
Builds and maintains working relationships with staff, referral sources, insurance companies, and medical providers.
Minimum Qualifications
High School diploma or GED equivalent with five (5) years of prior authorization experience OR Bachelor’s degree with two (2) years of prior authorization experience
Three (3) years of experience processing insurance requests to obtain prior authorization
Experience and familiarity with using insurance portals, i.e., Anthem, Availty, Evicor, Covermymeds, Magellang
Preferred Qualifications
Knowledge and experience with payer processes to submit appropriate clinical documentation
Experience using Medical Terminology
Knowledge, Skills, Abilities and Other Characteristics
Proficiency with Microsoft applications and internet-based programs
Strong interpersonal skills with the ability to establish strong working relationships
Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Strong time management skills to prioritize assignments and meet the designated deadline
Ability to anticipate, recognize, and meet the needs of the patients and their families
Ability to work in a team-based environment to accomplish goals and objectives
Ability to demonstrate respect and sensitivity for cultural diversity in client’s work force and patient population
Ability to critically think, problem solve and make independent decisions supporting the authorization process, including interactions with payer representatives, physicians, and hospital case managers