POSITION SUMMARY:

The Eligibility and Prior Authorization Specialist will be responsible for building and maintaining collaborative and productive relationships with internal and external stakeholders relating to eligibility and prior authorization, managing revenue cycle projects, driving performance in operations related to reimbursement and providing direction and oversight of processes impacting cash collections.

PRIMARY RESPONSIBILITIES:

• Serves as a source of knowledge for the designated revenue cycle function. 
• Performs analysis, identifies trends, presents opportunity areas, and prioritizes initiatives for performance improvement for the designated revenue cycle function.
• Responsible for developing appropriate workflows and tracking for the designated revenue cycle function.
• Establishes an ongoing working relationship with other departments impacting revenue cycle performance.
• Works closely with various vendor operations teams (Prior authorization, Claims and Appeals) to oversee operations activity that directly impacts the revenue cycle to accurately process actions in a timely manner for optimal reimbursement.
• Tracks outcomes of payment resolution, appeals, and negotiated claims to ensure goals are met.
• Leads weekly meetings to review key metrics, workflows, trends, and performance improvement opportunities.
• By continually reviewing and monitoring eligibility and prior authorization changes, researches, evaluates, and interprets guidance from a variety of sources to determine departmental actions.
• Coordinates with Management to ensure thorough understanding of trends/issues affecting revenue cycle performance.
• Develops goals and metrics to link department and revenue cycle initiatives with the organization’s strategy.
• Develops, manages and monitors successful completion of implementation and project plans.
• Acts as an educator on performance improvement requirements in operations and methodologies to related teams and departments.
• Continuously seeks new and creative technologies that help identify and guide improvement opportunities that align with overall company success.

Required Knowledge, Skills and Abilities:

• Proficiency with medical billing systems, Microsoft Excel, medical terminology and basic procedure coding knowledge.
• Knowledge of medical terminology and abbreviations, and health care nomenclature and systems.
• Strong communication (verbal and written), organizational, problem solving and team player skills.
• Ability to navigate across multiple customer demands and balance competing priorities successfully.
• Ability to analyze, identify and articulate identified trends and report trends succinctly in a clear and concise manner.
• Ability to solve problems using critical thinking skills.
• Maintains confidentiality of sensitive information.
• Analytical skills required.
• Ability to think critically and identify the impact across the revenue cycle with a solution oriented approach.
• Ability to develop, implement and produce analysis and reports

Qualifications: 

• At least 3 years of experience in medical billing and Insurance collections
• At least 3 years of experience with Eligibility and Prior Authorization requirements, payer utilization management policies and Appeals
• Knowledge of CPT/HCPCS. ICD-10, modifier selection  and UB revenue codes
• Bachelor’s Degree
• Healthcare related field of study or equivalent experience.