Job Summary: We are seeking a full-time prior authorization specialist responsible for verifying a patient’s insurance benefits, determining whether prior authorization is required for specific services, and obtaining necessary approvals from insurance companies before treatment or services can be provided. The specialist ensures that the patient’s care is covered and medically necessary in accordance with insurance guidelines.
Key Responsibilities:
- Acts as a liaison between healthcare providers, patients, and insurance companies to navigate the prior authorization process.
- Patient Information Verification: Review patient medical records, diagnoses, and insurance details to determine eligibility and coverage for requested services.
- Benefit Investigation: Contact insurance companies to verify coverage limitations, co-pays, deductibles, and prior authorization requirements for specific treatments or services.
- Documentation: Maintain detailed records of all prior authorization activities, including patient information, insurance details, communication with providers, and authorization status.
- Communication with Providers: Collaborate with healthcare providers to gather necessary medical information and documentation for prior authorization requests.
- Prior Authorization Submission: Complete and submit accurate prior authorization requests to insurance companies through electronic portals or paper forms, including clinical documentation to support medical necessity.
- Follow-up and appeals: Monitor the status of prior authorization requests, follow up with insurance companies on pending cases, and appeal denied requests with appropriate clinical rationale.
- Prior Authorization and Eligibility and Verification: Completes the prior authorization investigation and verifies patient eligibility for services invoices.
- Staying up to date: Keeping current on changes in insurance policies, medical codes, and prior authorization guidelines.
Qualifications & Skills:
- Medical Billing & Coding Knowledge - familiarity with ICD-10, CPT, and codes related to Ophthalmology
- Insurance & Prior Authorization Expertise - Understanding insurance policies, prior authorization processes, and medical necessity requirements.
- Electronic Health Records (EHR) and Practice Management Software - Experience with ophthalmology-specific EHRs like ModMed/EMA.
- Attention to Detail – Ability to ensure accuracy in patient information, authorization submissions, and follow-ups.
- Communication & Interpersonal Skills—Strong verbal and written communication skills to coordinate with providers, insurance companies, and patients.
- Problem-solving & Critical Thinking – Ability to resolve authorization denials and navigate insurance requirements effectively.
- Time Management & Organization – Handling multiple prior authorization requests efficiently while meeting deadlines.
- Confidentiality & Compliance – Understanding HIPAA regulations and maintaining patient data security.
- Experience in ophthalmology or a medical office setting, preferably in insurance verification or prior authorizations.
- Familiarity with Medicare, Medicaid, and commercial insurance plans.
- Bilingual (Spanish speaking) preferred
Benefits:
- Health insurance
- Dental Insurance
- Life Insurance
- Accidental Death & Dismemberment Insurance
- 401(K)
- PTO and holidays off
- Career growth and development