Prior Authorization Representative

General Summary of Duties

Prior Authorization Representatives are responsible for ensuring patients presenting for services are authorized and financially cleared prior to appointment date. The successful candidate will have a good understanding of procedure coding and can efficiently and effectively track and obtain authorizations with multiple payors and product lines.

Essential Duties and Responsibilities

Essential duties and responsibilities include the following. Other duties may be assigned.

  • Validates eligibility and benefits.
  • Obtains and documents prior authorizations for procedures and other services.
  • Provides cost estimates to private pay patients and obtains payments.
  • Interacts with provider medical staff as appropriate to communicate authorization denials and delays.
  • Follows HIPAA guidelines in handing patient information.
  • Assists Accounts Receivable staff with denials due to authorization issues.
  • Provides coverage and assistance to front reception staff as needed.
  • Completes projects as assigned to support process integration with other departments.

Education and/or Experience

  • Must demonstrate current competencies applicable to job position.
  • Professional, positive attitude and appearance.
  • Solid written and verbal communication with excellent math skills.
  • Ability to be resourceful and proactive when issues arise.
  • Excellent organizational skills.
  • Ability to multitask and prioritize assignments while maintaining attention to detail.
  • Knowledge on insurance and reimbursement processes.
  • Understanding of ICD-10 and CPT medical billing codes.
  • Familiarity with HIPAA privacy requirements which includes maintaining and protecting confidential information.

Hours of Operation

This position is scheduled Monday – Friday, 8:30am – 4:30pm. Hours may vary or change based on operational needs of the practice.

This position reports to the Billing Manager and has no supervisory responsibilities.

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