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Patient Accounts Prior Authorization Specialist

4 months ago

Rockford, United States ROCKFORD GASTROENTEROLOGY ASSOCIATES LTD Full time

Description:
**Overall Summary**:
RGA is seeking a detail-oriented and experienced Prior Authorization Specialist Group Lead to join our team. In this role, you will be responsible for obtaining prior authorizations from insurance companies for medical procedures, medications, and services to ensure timely and accurate reimbursement for our patients. Oversee a team responsible for executing pre-registration and prior authorization activities. Provide guidance and support to team members, delegate tasks, and conduct performance evaluations.

**Key Responsibilities**:

- **Prior Authorization and Pre-Registration Group Lead**:

- Managing processes, ensuring compliance with regulations and standards, and continuously improving processes.
- Conduct training sessions for team members to ensure they understand pre-registration and prior authorization processes thoroughly. Provide ongoing support and guidance to improve team performance and efficiency, delegate tasks and conduct performance evaluations.
- Continuously assess and improve pre-registration and prior authorization processes to enhance efficiency, effectiveness, and customer satisfaction. This includes soliciting feedback from stakeholders and implementing process improvements with the manager’s approval.
- Serve as a primary point of contact for internal and external stakeholders regarding pre-registration and prior authorization matters. This includes communicating registration deadlines, providing updates on authorization status, and addressing inquiries or concerns from stakeholders.
- **Prior Authorization Process**:

- Review patient medical records and treatment plans to determine the need for prior authorizations.
- Initiate and complete prior authorization requests with insurance companies via phone, online portals, and written correspondence.
- Gather necessary documentation, such as medical reports, test results, and prescription details, to support authorization requests.
- **Insurance Verification**:

- Verify patients' insurance coverage and benefits for specific procedures or services requiring prior authorization.
- **Follow-up and Appeals**:

- Monitor the status of prior authorization requests and follow up with insurance companies as needed to expedite approvals.
- Coordinate with healthcare providers to address any additional information or appeals required for denied authorizations.
- Document all communication and actions related to prior authorizations in the electronic health records (EHR) system.
- **Compliance and Documentation**:

- Ensure compliance with insurance guidelines, regulatory requirements, and billing policies during the prior authorization process.
- Maintain accurate records of authorization numbers, approval dates, and authorization periods for billing and reimbursement purposes.
- Assist with coding and billing tasks related to authorized services and procedures.
- Other Duties assigned by Manager.

**Key Competencies**:

- Problem-solving skills to identify root causes of claim denials.
- Ability to prioritize tasks and manage multiple appeals simultaneously.
- Team player with a collaborative approach to work.
- Adaptability to changing insurance policies and billing requirements.
- Strong organizational skills to maintain detailed appeal records.

**Requirements**:
**Qualifications**:

- High school diploma or equivalent; associate or bachelor's degree in healthcare administration or related field preferred.
- Minimum of 2 years of prior authorization experience in a medical setting, preferably in a hospital or clinic.
- Knowledge of medical terminology, CPT/HCPCS codes, and insurance billing procedures.
- Familiarity with electronic health records (EHR) systems and insurance verification tools.
- Strong communication skills with the ability to interact professionally with patients, healthcare providers, and insurance representatives.
- Excellent organizational skills and attention to detail to ensure accuracy in documentation and follow-up.