Prior Auth Executive with coding knowledge

We are looking to recruit an experienced Prior Authorization executive who also has a knowledge on CPT / HCPCS Codes as well and can work Independently.

Role & responsibilities

• Pain management experience is preferred
• Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services / procedures
• Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt
• Knowledge in Medical Terminology, knowledge of the different types of health insurance plans: i.e., HMO, PPO, POS etc.
• Obtains prior-authorizations and referrals from insurance companies prior to procedures or Surgeries utilizing online websites, via telephone or FAX
• Obtains and/or reviews patient insurance information and eligibility verification to obtain prior-authorizations for injections, DME, Procedures, and Ambulatory surgeries
• Provides insurance company with clinical information necessary to secure prior-authorization or referral. - Good understanding of the medical terminology and progress notes
• Review doctor consultation notes to properly answer clinical questions
• Coordinates and supplies information to the Insurance company including medical information and / or letter of medical necessity for determination of benefits
• Document the detail notes and attach the approved Auth/Referral to patient encounters
• Monitors and updates current Orders and Tasks to provide up-to-date and accurate information
• Collaborates with designated clinical contacts or Providers regarding encounters that require escalation to peer-to-peer review.
• Communicates with clinical partners and others as necessary to facilitate authorization process
• Request retro-authorizations when needed. - Communicates with practices when prior
• authorization is unable to be obtained and requires peer-to-peer and/or different study
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
• Completes accurate documentation in both the Auth / Cert and Referrals
• ENSURES TIMELY AND ACCURATE INSURANCE AUTHORIZATIONS ARE IN PLACE PRIOR TO SRRVICE BEING RENDERED
• Follows departmental policies and procedures (Alerting front desk to get ABN signed,), when the necessary authorization is not obtained prior to service date
• Answers provider, staff and patient questions surrounding insurance authorization requirements.
• Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations
• Communicate any insurance changes or trends among team
• Clearly document all communications and contacts with providers and personnel in standardized documentation requirements, including proper format
• Denial management, finding trends / Medical policies beneficial for pre-auth process / Identify and report trends and prior authorization issues relating to billing and reimbursement
• Performs other related duties as required or assigned
• Generate self-productivity reports for supervisory review
• Minimum 1 year experience in initiating and following prior-authorization / Referrals etc.
• Experience in diagnosing, isolating, and resolving complex issues and recommending and implementing Strategies to resolve problems

Preferred candidate profile

• CPC or CCS is MUST
• Healthcare RCM knowledge, preferred
• Analytical skills and good communication skills
• Ability to clearly articulate actions taken and articulate next steps
• Should be willing to work in Night shift
• Excellent written and verbal English
• Ability to multitask
• Good computer skills including MS Excel, MS Word, Google Drive
• Minimum 1 year experience in initiating and following prior-authorization (Pain management preferred)
• Knowledge of key medical and billing terms
• Consistent attendances during night shift
• Quick and eager to learn and mold accordingly to the process needs
• Ability to effectively handle multiple priorities within a changing environment
• Life Science Graduate OR any stream with relevant work experience

Perks and benefits

Best in the industry but will be discussed only after interview