BPN (Clinics) Insurance Verification and Authorization Specialist

General Summary

Reviews procedures, referrals, and prescription medications with applicable insurance policies to ensure compliance and maximize reimbursement.

Principal Job Functions

• Serves as a resource and liaison to hospital departments, physician offices, and patients for pre-service authorization.
• Adheres to regulatory guidelines such as Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA, and HIPAA.
• Maintains productivity and quality standards as defined by organizational and departmental goals.
• Communicates with insurance companies, physician offices, and patients regarding authorization of services and retro-authorizations.
• Documents all actions taken in the authorization process accurately and completely.
• Ensures pre-certification and authorization requirements are met by contacting insurance companies, physician offices, and patients.
• Provides effective communication with patients, family members, team members, physicians, and other healthcare providers.
• Coordinates obtaining waivers of liability when third-party payers deny coverage or services.
• Prepares and provides patients with estimates for services and connects them to the estimates team.
• Maintains accurate payer website information and logs into systems for authorization requirements.
• Communicates with Patient Financial Services regarding denials and appeals/reconsideration letters.
• Maintains professional growth and development through seminars, workshops, and professional affiliations.
• Participates in meetings, committees, and department projects as assigned.

Education and Experience

• High school diploma and one (1) year relevant work experience in a medical clinic, health care, insurance industry, pharmacy, or medical billing office required.
• Certified Medical Assistant or Medication Aide, coding certificate, or other clinical background preferred.
• Must be 19 years of age to witness legal consents.