General Description:

The Prior Authorization Specialist is responsible for identifying third party payer requirements and obtaining the necessary authorizations for care, including verifying eligibility, obtaining insurance benefits, and ensuring that pre-certification, prior authorization, and referral requirements are met prior to the delivery of patient care. The position is also responsible for medication prior authorization to support prescribing of medications.

The Prior Authorization Specialist provides detailed and timely communication to both payers and providers in order to facilitate compliance with payer contractual requirements and timely delivery of patient care.

Job Responsibilities

• Verifies insurance eligibility and benefit levels for referral orders and prescribed medications for a busy internal medicine practice.
• Understands pharmacy benefit management processes, including prior authorization for medications not on formulary.
• Successfully works with payers via electronic/telephonic and/or fax communications.
• Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.
• Completes accurate documentation to obtain Prior Authorizations in a timely manner.
• Collaborates with designated clinical contacts regarding authorizations that require escalation to peer-to-peer review.
• Communicates with patients, clinical providers, financial counselors, and others as necessary to facilitate authorization process.
• Uses the electronic medical record for documentation and communication with practice staff and patients.
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
• Understands primary and secondary insurance requirement, including adherence to Federal guidelines for Medicare / Medicaid.
• Ensures timely and accurate insurance authorizations are in place prior to services.
• Follows medical practice policies and procedures.
• Serves as a subject matter expert to providers, staff and patients regarding the insurance authorization process.
• Supports co-workers to maintain a positive and collaborative work environment.
• Other duties as assigned.

Required Skills and Qualifications

• Minimum of two years’ experience in medical practice billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare, Medicaid, HMO's and PPO's required.
• Prior experience in a business office position with strong customer service background preferred.
• Knowledge of online insurance eligibility systems required.
• High School diploma required.
• Proficiency in MS Office (Outlook, Word, Excel, PowerPoint, etc.) required.
• Experience with electronic medical record systems preferred.
• Familiarity with Medical Terminology
• Excellent written and verbal skills
• Exceptional customer relations skills required
• Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity.