Prior Authorization

Description

• ·      Submits, tracks, and manages prior authorization requests for medical and ancillary procedures, within strict timeframes.
• Researches and resolves authorization and referral claim denials, while coordinating with physicians, providers, and insurance payers to file appeals or facilitate a P2P.
• Reviews patient medical records and clinical documentation to ensure they meet payer coverage criteria.
• Collaborate with the RCM Prior Authorization Supervisor and Team Lead to develop and update authorization policies and procedures.
• Maintain knowledge of payer guidelines (Medicare, Medicaid, Commercial, etc.) and ensuring regulatory compliance.
• Partner with the RCM Prior Authorization Supervisor and Team Lead to analyze denied claims resulting from prior authorization and referral errors by identifying the root cause and provide the corrected data to the billing team for the purpose of appealing or resubmitting a corrected claim.
• Interacts with insurance payers, physicians, providers, and Slocum departments to clarify coverage requirements to expedite approvals.
• Work in collaboration with the RCM Prior Authorization Supervisor and Team Lead to monitor prior authorization related utilization trends, claim denials, denial rates, and provide performance improvement suggestions to senior leadership.
• Communicate cross-functionally with providers and other Slocum departments regarding patient questions or referral and authorization concerns.
• Perform other duties as assigned.

Requirements

• 2 – 5 years of previous experience as a Prior Authorization Specialist, with expertise in medical billing, healthcare, and the insurance referral process.
• Strong understanding of medical terminology, ICD-10, CPT, and HCPC coding, and insurance payer policies.
• Ability to train staff, manage high-volume workflows, and mentor team members.
• Proficiency in medical billing software / Electronic Health Records (NextGen preferred).
• Be able to read and understand digital and paper insurance Explanation of Benefits.
• Strong attention to detail (Accuracy in code selection is critical for compliance and reimbursement.
• Familiarity with CMS and insurance payer guidelines and requirements.
• Proficient with Microsoft Office Suites (Outlook, Word, and Excel).
• Possess the ability to prioritize workload daily, weekly and monthly.
• Strong communication, attention to detail, and problem-solving skills

Summary

The RCM Prior Authorization Specialist manages insurance approvals for medical and ancillary services.  Monitor the accuracy of prior authorization activity and payer requirements.  Act as a liaison between providers, patients, payers.  Ability to learn and retain new workflows and changes in insurance payer requirements.  Ensure a high level of accuracy in clinical documentation submissions.  Handle denials and appeals.