Prior Authorization Specialist

Position Purpose:

This position is responsible for working closely with Patient, Patient Access, Payers, and Providers' office to validate insurance plans, eligibility, and orders to procure required prior authorizations.

Organization:

This position reports to the designated Operations Manager for Signature Performance.

Essential Job Functions include the following. Other duties may be assigned.

• Collaborate with insurers to obtain pre-authorizations for condition-specific medications, diagnostic procedures and treatments, and support patients in navigating barriers / coverage and disputes.
• Submit prior authorization requests for medical procedures, diagnostic tests, treatments, and medications as required by insurance providers.
• Gather, review, and submit all necessary clinical documentation to support authorization requests, ensuring accuracy and completeness.
• Communicate with insurance representatives to clarify requirements, resolve authorization denials, and follow up on pending approvals.
• Collaborate with physicians, nurses, and other clinical staff to obtain additional clinical information or documentation required by insurance companies.
• Inform patients about the status of their authorization requests, answer questions regarding coverage, and provide guidance on next steps.
• Maintain accurate and detailed records of all prior authorization requests, outcomes, and patient information in compliance with HIPAA regulations.
• Stay updated on changes in insurance policies, state and federal regulations, and organizational policies affecting prior authorizations and reimbursement.
• Meet quality and productivity standards set by Signature and/or our client.
• Provide excellent customer service in keeping with Signature's legacy both internal and externally.
• Maintain expertise in multiple current client systems.
• Maintain up to date knowledge of revenue cycle management, industry trends perform other duties as necessary.
• Acts as an effective team member.

Knowledge & Experience:

• Minimum 2 years of prior authorization experience, insurance coordination, or case management within a physician office, hospital, or insurance plan authorizations unit.
• Understanding of healthcare insurance systems
• Preferred experience and understanding of medical terminology
• General knowledge of CPT/HCPCS and ICD-10
• Strong written and verbal communication skills with the ability to explain complex medical and insurance information
• Strong attention to detail
• Passion for patient advocacy with a problem-solving mindset, focusing on overcoming challenges to accessing care.
• Ability to work effectively both independently and as part of a multidisciplinary team
• Computer proficiency including Microsoft Office, Word, Excel and Outlook
• Ability to function effectively in a fast-paced environment.
• Personal traits of a high-level commitment, motivation, energy, team orientation, professionalism, trust, personal honesty and integrity, and a demonstration of placing others in a place of high value.

General AREAS OF Accountability:

Must conduct business and personal affairs in a manner that is always a credit to the company. Must maintain a good credit rating while employed with the company.

Machines and Equipment:

The applicant must be able to effectively operate the current computer system, telephone system, and other office machines such as copier and fax machines.

Physical Activity:

The applicant must be able to finger, grasp, feel, see, sit, hear, and speak. This position is sedentary in nature with minimal lifting requirements.

WORKING CONDITIONS:

The applicant works in an office environment that is not substantially exposed to adverse environmental conditions such as heat, cold, or extreme noise. Routine periods of sitting and data keying are required.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.