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Prior Authorization Specialist

5 months ago

Albuquerque, United States Southwest Women's Oncology Full time
Job DescriptionJob Description

A highly successful, robust Women’s medical practice is seeking a full time Prior Authorization Specialist for their busy three location practice. This Monday-Friday position offers great hours with no nights, weekends, or holidays and a comprehensive benefit package.

The Prior Authorization Specialist works with departments and insurance companies to obtain the necessary pre-certifications and authorizations for services ordered, scheduled by Southwest Women’s Oncology. The Prior Authorization Specialist maintains a high level of understanding of insurance companies and billing authorization requirements.

Major Responsibilities:

· Obtain pre-authorization from insurance carriers for medical services within a designated time frame.

· Follow up and secure prior authorizations prior to service appointments. Demonstrate proficiency in medical terminology and general medical office procedures, including HIPAA regulations.

· Maintain a productive work rate suitable for the department.

· Record all communication with providers and personnel in standardized documentation with the proper format.

· Review denial reasons and advocate for patients while obtaining approval/denial letters, informing the office of results, and providing appeal services.

· Build relationships with physician offices and clinics by initiating contact via email, answering phone/email correspondence promptly, and responding within one business day.

· Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients.

· Follows up with physicians, patients, and third-party payers to complete the pre-certification process.

· Collaborates with Supervisor, internal departments and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.

· Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.

· Educates patients, staff and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.

· Ensures all services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance.

· Notifies patient accounts staff/patients of insurance coverage lapses, and self-pay patient status. May notify ordering providers if authorization/certification is denied.

· May coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.

· Maintains files for referral and insurance information. Enters referrals into the system.

· Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.

· Serves as an expert for peers across the patient access continuum.

· Meets daily productivity and quality standards associated with job requirements.

· Performs other job-related responsibilities as requested.

Work Experience:
REQUIRED
2-3 years of experience in healthcare with insurance and/or prior authorization experience.

DESIRED
3-4 years in a health care related field

License and Certifications:
DESIRED

· Medical Billing Certificate

· Certified Professional Coder

· Certified Coding Specialist

Benefits:

We offer a full benefits package, competitive salary and secure parking. Staff members have access to our performance center complete with a full AI gym suite, recovery modalities, group fitness classes, and body composition tracking.

Company DescriptionThis is your opportunity to join the high-performance team that is Southwest Women's Oncology.

Our team brings all available resources together to help our clients achieve their Optimum Self in any aspect of their lives, or in simple terms: to be as good as they can be for as long as they can do it. We are a world-class medical practice with specialties in gynecologic oncology, women’s healthCompany DescriptionThis is your opportunity to join the high-performance team that is Southwest Women's Oncology.\r
\r
Our team brings all available resources together to help our clients achieve their Optimum Self in any aspect of their lives, or in simple terms: to be as good as they can be for as long as they can do it. We are a world-class medical practice with specialties in gynecologic oncology, women’s health