Description

Summary of Role

The Pre-Authorization Specialist is responsible for verifying eligibility, obtaining insurance benefits, and ensuring pre-certification, authorization, and referral requirements are met before delivery of inpatient, outpatient, and ancillary services. This role involves coordinating with healthcare providers to secure necessary referrals.

Key Responsibilities

• Obtain authorizations and pre-determinations from insurance companies for all required services.
• Receive verification of benefits from insurance. Confirm patient eligibility through direct communication with insurance companies and online portals.
• Enter new/updated patient information into the computer system. Ensure all necessary documentation is complete, accurate, and submitted promptly.
• Determines patient payer authorization requirements to obtain the necessary authorization. Provide updates to relevant parties regarding the status of authorizations and potential issues.
• Track the status of pre-authorizations daily. Notify administrative assistants before due dates and serve as a resource to clinical staff to facilitate timely completion.
• Responsible for documenting the appropriate information in the patient's record and ensuring referrals are in place where necessary. Maintain accurate and detailed records of all insurance verifications, authorizations, and referrals.
• Liaise with patients, healthcare providers, and insurance companies to resolve any insurance coverage and authorization issues.
• Ensure all actions comply with hospital policies, state and federal regulations, and insurance guidelines.
• Perform other office duties when backup coverage is needed.

Requirements

Qualifications

• High School Diploma or equivalent
• Minimum two years of experience in medical insurance verification, pre-authorization, or a related role
• Experience in an orthopedic or surgical setting preferred
• Proficiency in using electronic health records (EHR) and insurance verification software.
• Experience using EPIC and Microsoft Office preferred.
• Ability to communicate effectively in verbal, nonverbal, and written forms. 
• Strong understanding of insurance policies, pre-certification, and authorization processes.

Physical and Mental Demands

Communication Skills

Ability to clearly explain the pre-authorization process, including the required documentation and the expected timelines, to patients and healthcare providers. Maintain a professional manner in all interpersonal interactions. Work effectively with billing departments and other hospital staff to ensure a coordinated approach to pre-authorization. 

Mathematical Skills

Basic arithmetic is necessary, as well as interpretation and analysis of insurance plans, statements and financial data to ensure accuracy. Using spreadsheet software like Microsoft Excel to organize, analyze, and present financial and insurance data.

Judgement and Decision Making

Working collaboratively with healthcare providers, administrative staff, and insurance representatives. Handling conflicts or misunderstandings calmly and effectively to ensure smooth operations. Quickly identifying potential issues in the pre-authorization process and finding effective solutions. Utilizing available resources and information to resolve issues efficiently. 

Software and Technology

Understand and correctly use medical and insurance terminology to communicate effectively with professionals and accurately document information. Navigate electronic health records (EHR) and insurance verification systems, communicating findings and updates through these platforms. Have the capability to proficiently use EPIC and Microsoft Office in everyday work.

Work Environment

The primary work environment is office-based. The noise level in the work environment is usually moderate.