Prior Authorization Specialist

Job Title: Prior Authorization Specialist

Position Description: Performs various access-related duties to include but not limited to, eligibility/insurance verification for services, obtaining authorization/referrals, scheduling, canceling, rescheduling, point of service payments, general appointment information and directions.

Reports to: Revenue Cycle Supervisor

MISSION

Provide strong and exceptional customer service skills and ability to follow policies regarding insurance verification. Authorizes and pre-certifies services by coordinating and performing activities required for verification and authorization of insurance benefits for services and communicate the patient’s financial responsibility. Proactively identifies resources for patients and may communicate the financial resources available to patients whose health plan does not include coverage for services. Ensure the patient’s confidentiality and integrity are maintained to the highest standards.

OUTCOMES

• Interviews patients and/or family members as needed to secure information concerning insurance coverage, eligibility, and qualification for various financial programs.
• Coordinates and performs verification of insurance benefits for every visit by contacting insurance company /website and determining eligibility of coverage and communicates status of verification/authorization/referral process with appropriate team members in a timely and efficient manner.
• Provides clinical information as needed, emphasizing medical justification for procedure/service to insurance companies for completion of authorization/referral process.
• Acts as a liaison between clinical staff, patients, physician, insurance payor, external vendors (ex: drug reps, pharmacy,) forming patients of referral or authorization/benefit delays/denials, answering questions, educating patients about their benefit, and offering assistance.
• Maintains tracking of patients on schedule, ensuring that the correct insurance plan, eligibility, referral and authorization information has been entered into data entry systems accurately along with documenting applicable notes or review secure notes.
• Calculate estimated patient responsibility to inform the patient and document in the data entry system.
• Adhere to the Collections Policy to ensure patients are aware that payment is due at time of service and responsible for setting up payment arrangements.
• Collect payment prior to or on the date of service.
• Reschedule/cancel patients in the data entry system accordingly due to verification/authorization related issues.

COMPETENCIES

Job Related Competencies:

1. Ensures Accountability: Holding self and others accountable to meet commitments.
2. Action Oriented: Taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm.
3. Manages Conflict: Handling conflict situations effectively, with a minimum of noise lens.
4. Interpersonal Savvy: Relating openly and comfortably with diverse groups of people.
5. Drive Results: Consistently achieving result, even under tough circumstances.
6. Financial Acumen: Interpreting and applying understanding of key financial indicators to make better business decisions.

Cultural Competencies:

Advanced Values:

1. People
   • Collaborates: Building partnerships and working collaboratively with others to meet shared objectives
2. Heart
   • Patient Focus: Building strong patient relationships and delivering patient centric solutions.
3. Service
   • Instills Trust: Gaining the confidence and trust of others through honesty, integrity, and authenticity.
4. Excellence
   • Cultivates Innovation: Creating new and better ways for the organization to be successful.

Behaviors:

1. Being Resilient:
   • Rebounding from setbacks and adversity when facing difficult situations
2. Self-Development:
   • Actively seeking new ways to grow and be challenged using both formal and informal development challenges.
3. Optimizes Work Processes:
   • Knowing the most effective and efficient processes to get things done, with a focus on continuous improvement.
4. Professional Communication:
   • Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences, while maintaining a professional appearance and tone.

QUALIFICATIONS

Basic Qualifications:

Education:

• High School Diploma or GED

Previous, Job Relevant Work Experience:

• 2 years of experience in insurance verification, financial counseling, billing, scheduling, equivalent externship, or access related position
• Working knowledge of basic medical terminology
• Ability to work independently in a changing environment and handle stressful situations.
• Must be able to speak and write in a clear and concise manner to convey messages and ensure that the customer understands whether clinical or non-clinical.
• Proficient in Microsoft Word/Excel/Outlook, and insurance websites
• May require travel within Metro Atlanta as needed.
• Demonstrate a high level of professional conduct with colleagues, superiors, and internal/external customers.
• Attend mandatory meetings/training in the office when necessary.