Manager For Insurance verification, Referrals & Pre-authorizations

This position appears to be focused on managing the Teams of Insurance Eligibility, Prior Authorization and referral processes efficiently within the US healthcare system, requiring experience and knowledge in handling insurance coverage, patient benefits verification, and effective communication with both patients and healthcare providers along onsite team.

Process:

• Obtains prior-authorizations and referrals from insurance companies prior to procedures or Surgeries utilizing online websites or via telephone.
• Monitors and updates current Orders and Tasks to provide up-to-date and accurate information.
• Provides insurance companies with clinical information necessary to secure prior- authorization or referral.
• Good understanding of the medical terminology and progress notes.
• Obtains and/or reviews patient insurance information and eligibility verification to obtain prior-authorizations for Radiology, Cardiology, injections, DME, Procedures, and surgeries.
• Request retro-authorizations when needed.

Preferred candidate profile

• Minimum 10 years experience in Pre- authorization and RCM Process.
• Good knowledge in Medical Terminology.
• Experienced in reading clinical documents and relating it to the service.
  • Strong Communication skills - Should be able to communicate with providers at the insurance.

Role & Responsibilities:

• Work with team to Processes prior authorizations and referral requests promptly, ensuring they are completed before patient services commence.
• Periodical meetings with client regarding weekly and monthly work flow. Understanding client issues and working with the team to sort out the issues.
• Understanding on Providers and payers requirement and should be able to train the team accordingly.
• Making strong follow up and Coordination between client and Team with weekly and monthly reports .
• Researches patient member benefits, coverage limitations, and allowances to secure necessary authorizations and referrals for patient services.
• Manage the team which receives and manages referral requests from providers and health plans related to patient visits and procedures.
• Verifies member eligibility and benefits using health plan provider portals or eligibility services, accurately entering information into the EMR system for authorization tracking.
• Educates patients and team on coverage details and any necessary insurance carrier contacts for additional services.
• Coordinates with providers, physicians, and medical personnel to gather required documentation and codes for authorizations and referrals.
• Communicates authorization details and coverage information promptly to relevant department staff.