Prior Authorization Specialist

Responsibilities

• Contacts a patient’s insurance company to verify coverage and initiate authorizations.
• Determines CPT, HCPCS, and ICD-10 codes for proper Prior Authorization.
• Verifies physician orders are accurate and communicates insurance co-pays, deductibles, co-insurances, and out-of-pocket expenses for point of service collections.
• Maintains communication with providers, clinical staff, and patients regarding authorization status.
• Works with the billing department to research and resolve rejected, incorrectly paid, and denied claims.
• Helps maintain a professional atmosphere for patients, family members, and staff.
• Remains current with insurance requirements for pre-authorization and educates within departments and clinics on changes.
• Keeps management informed of changes in authorization process, insurance policies, billing requirements, rejection or denial codes.
• Communicates with providers, clinical staff, payors, and patients to answer questions and offer information.
• Suggests improvements and participates in efforts to improve service levels.

Requirements

• High school graduate or equivalent.
• Knowledge of CPT, HCPCS, and ICD-10 codes preferred.
• Three to five years of experience working in a hospital, doctor's office, or billing setting.
• One to two years of procedure and/or medication authorization experience required.

Qualifications

• Medical terminology required.
• Proficient with MS Office Suite including Word, Excel, and PowerPoint.
• Proficient with the EMR system.
• Excellent time management and organization skills with attention to detail.
• Good judgment to handle situations appropriately.
• Ability to use online resources and tools efficiently.
• Multi-tasking using several systems and multiple monitors at the same time.

Skills

• Effective presentation and response to questions.
• Solving practical problems and dealing with various concrete variables.
• Interpreting instructions in written, oral, or scheduled forms.
• Good customer service (AIDET).
• Handling conflict.
• Exercising good judgment to handle situations appropriately.

Benefits

Pre-employment drug and alcohol screening is required.

Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer.