Authorization Representative

Job Duties

• Collaborates with physicians and provider office staff in securing appropriate authorization, referral based on medical necessity and the patients’ treatment plan.
• Performs medical necessity review to ensure procedures and diagnoses meet payer requirements.
• Obtain authorizations in compliance with network policies and communicate any exceptions to ordering office, patient, and manager.
• Interfaces with insurance companies, both directly and indirectly, to verify coverage, benefits and obtain precertification.
• Reviews and verifies additional clinical information, insurance authorizations and referrals as needed.
• Maintains compliance with benchmark metrics for accounts registered versus scheduled procedures.
• Calculates estimated patient financial responsibility using insurance verification, payer contracts, and self-pay guidelines.

Minimum Qualifications

• A high school diploma or GED
• One year of experience in healthcare insurance verification, prior authorization requirements, and insurance benefits structures.
• Experience working with multiple insurance payers and understanding medical necessity requirements.
• Prior experience working with electronic health record (EHR) systems and insurance portals.
• Familiarity with clinical documentation and interpretation of treatment plans.
• Knowledge of CPT, ICD-10 and HCPCS coding as it relates to authorizations.
• Knowledge of patients' rights and laws relative to patients' rights such as HIPAA.

Preferred Qualifications

• A degree in health administration, healthcare management or a related field preferred.