Prior Authorization Specialist – Billing Department

Description

Rheumatology Associates is seeking a detail-oriented Prior Authorization Specialist to join our Billing Department. This position will be responsible for managing the prior authorization and benefit verification process for specialty/injection medications for scheduled and upcoming potential injection appointments.

The Prior Authorization Specialist will work closely with providers, clinical staff, scheduling, billing, insurance companies, and other departments to ensure required authorizations and benefits are obtained accurately and timely to prevent delays in patient care and billing.

 Essential Duties and Responsibilities

• Obtain and manage prior authorizations for specialty medications/injection therapies.
• Verify insurance coverage and determine authorization requirements a minimum of four (4) weeks prior to scheduled service dates whenever possible.
• Submit, track, and follow up on authorization requests through payer portals, electronic systems, fax, and telephone communications.
• Review patient records and clinical documentation within eClinicalWorks (eCW) to ensure complete and accurate information is submitted for authorization requests.
• Accurately document authorization approvals, denial information, approval numbers, effective dates, approved doses or units, frequency, expiration dates, and other relevant details in eCW and applicable systems.
• Monitor pending authorizations and proactively follow up with insurance carriers to avoid delays in treatment or scheduled services.
• Review upcoming schedules for missing, expired, or incomplete authorizations and communicate issues promptly to the appropriate clinical, scheduling, or billing staff.
• Address injection-related claims, telephone encounters, authorization inquiries, benefit validations, and email correspondence in a timely manner each day.
• Interpret patient insurance benefits and accurately document benefit information within patient accounts to support patient communication and financial transparency.
• Meet productivity expectations while maintaining a high level of accuracy and attention to detail.

Requirements

• Previous experience in medical prior authorizations, insurance verification, medical billing or related healthcare billing role preferred.
• Experience with eClinicalWorks (eCW) strongly preferred.
• Experience obtaining prior authorizations for specialty medications, biologics, infusions or injectable therapies strongly preferred.
• Knowledge of commercial insurance, Medicare, and authorization requirements.
• Ability to interpret insurance benefits and effectively communicate benefit information to patients.
• Experience utilizing insurance payer portals and electronic authorization systems.
• Working knowledge of medical terminology, diagnosis coding, and clinical documentation.
• Strong organizational skills with the ability to manage a high volume of authorizations and competing deadlines.
• Demonstrated ability to multitask, prioritize workload, and adapt to changing priorities.
• Excellent written and verbal communication skills with the ability to work effectively with providers, clinical staff, billing personnel, insurance representatives, and patients.
• Strong attention to detail, problem-solving skills, and commitment to accuracy.