• Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt. • Successfully works with payers via electronic/telephonic and/or fax communications. • Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services.
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Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services before receipt.
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Successfully works with payers via electronic/telephonic and/or fax communications.
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Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services.
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Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.
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Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
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Communicates with patients, clinical partners, financial counselors, and others as necessary to facilitate the authorization process.
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Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
- Completes accurate documentation in both the Auth/Cert and Referral Shells.
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Determines Medicare primacy based on Federal guidelines.
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Determines inpatient Medicare coverage for days exhausted and hospice entitlement.
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Ensures timely and accurate insurance authorizations are in place prior to services being rendered.
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Follows departmental policies and procedures, when necessary, authorization is not obtained prior to service date.
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Answers provider, staff, and patient questions surrounding insurance authorization requirements.
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Other duties as required.
The Prior Authorization Specialist is responsible for all aspects of the prior authorization process. Responsibilities include collecting all the necessary documentation, contacting the client for additional information, and completing the required prior authorization to proceed with testing. Complete, timely, and accurate identification and submission of prior and retro authorization requests to the payors. Interacts with clients, insurance companies, patients, and sales representatives, as necessary, to request prior authorizations. Provides the highest level of customer service to internal and external clients.
