Are you a caring individual looking for a place where your expertise will be valued, your knowledge expanded, and your abilities challenged? CVAM is a place where employees know they are part of something bigger than themselves, take exceptional pride in their work, and are committed to continuous growth and excellence. This opportunity allows you to collaborate with an exceptional team, contribute to our shared success, and focus on what matters most—our patients.
CVAM offers a comprehensive benefits package designed to provide peace of mind both in and out of the workplace. We are committed to supporting our employees with competitive health benefits, paid time off, continuing education opportunities, retirement planning, and resources that help meet personal and family needs now and in the future.
Job Overview: The Eligibility, Referral, and Authorization Specialist verifies insurance eligibility and benefits, obtains and manages prior authorizations for in-office testing, and coordinates primary care referrals to ensure patients are appropriately cleared for services while supporting efficient clinical operations and revenue cycle performance.
The shift schedule is 7:30am-3:30pm Monday through Friday.
RESPONSIBILITIES:
- Review appointment schedules daily for the current date through five (5) business days in advance, including same-day add-on appointments, to identify referral, authorization, and eligibility requirements. Review appointments scheduled up to two (2) weeks in advance for in-office testing requiring prior authorization (including ultrasound, nuclear stress testing, PET, Holter monitoring, and wireless telemetry).
- Obtain required referrals and prior authorizations by contacting referring providers, primary care providers (PCPs), and health plans as appropriate.
- Contact patients to obtain or verify insurance information as needed.
- Verify patient eligibility, benefits, and coverage prior to scheduled services.
- Update patient accounts with accurate demographic, insurance, and other required information.
- Ensure all required referrals and authorizations are obtained and patient eligibility is verified prior to the scheduled appointment.
- Scan or save referral, authorization, and insurance-related documentation as PDF files and upload them to the patient's electronic medical record (EMR) or ezAccess, as appropriate.
- Coordinate peer-to-peer reviews between providers and insurance carriers when required and prepare or submit written appeals when appropriate.
- Notify the Front Office Manager no later than forty-eight (48) hours prior to a scheduled appointment when a required referral or authorization has not been obtained.
- Respond promptly to telephone calls, Microsoft Teams messages, and inquiries from patients and CVAM staff regarding referrals, eligibility, and authorizations.
- Create and update referral and authorization cases within the practice management system, ensuring accurate documentation for each date of service prior to claim submission.
- Assist the billing department with questions related to claims, referrals, authorizations, post-service insurance corrections, retroactive authorization requests, and referral issues.
- Monitor the EMR desktop, email, and other assigned communication channels daily, responding to referral receipts and internal communications within twenty-four (24) hours.
- Notify the ERA Lead of barriers or delays in obtaining referrals or authorizations from insurance carriers or provider offices.
- Collaborate with the ERA Lead to resolve complex referral and authorization issues involving primary care or referring provider offices.
- Communicate changes in insurance carrier or provider office referral and authorization requirements to the ERA Lead.
- Participate in educating clinic staff regarding referral, authorization, and eligibility processes as they relate to their job responsibilities.
- Demonstrate excellent written and verbal communication skills while providing exceptional customer service to internal and external customers.
- Maintain professionalism and composure while effectively managing multiple priorities in a fast-paced environment.
- Document all patient interactions and insurance-related activities accurately, thoroughly, and promptly within the patient's medical record.
- Maintain strict confidentiality and comply with all HIPAA and organizational privacy requirements.
- Complete all required new hire, annual, and ongoing education and training as a condition of employment.
- Perform other duties as assigned.
GOALS AND OBJECTIVES
- Verify patient eligibility, benefits, and insurance information and update the patient record at least five (5) business days prior to the scheduled appointment, or immediately upon notification for STAT, urgent, or same-day add-on appointments.
- Maintain referral, authorization, and eligibility work queues to ensure appointments scheduled at least five (5) business days in advance are reviewed and processed in a timely manner.
- Ensure all required referrals and authorizations are obtained and documented for all current-day appointments and appointments scheduled for the following business day.
- Minimize appointment delays, cancellations, and rescheduling due to missing referrals, authorizations, or eligibility issues.
- Meet departmental productivity and quality standards by accurately processing referrals and authorizations while maintaining complete and timely documentation.
- Maintain effective communication with patients, providers, insurance carriers, and internal departments to facilitate timely resolution of referral and authorization issues.
- Escalate unresolved referral, authorization, or payer issues to the ERA Lead in a timely manner to support continuity of patient care and revenue cycle performance.
Pay: From $19.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
