Authorization Specialist

Valley Health Partners; United States; Remote; USD 46,000 - 62,000; Full time

Benefits offered by this job

Medical, dental, and vision plans

403b Retirement Plan with companymatch

Paid Time Off

Employee Assistance Program

Tuition Reimbursement

Job summary

Valley Health Partners is seeking a detail-oriented Benefits and Authorizations Specialist to obtain approvals for surgical procedures, diagnostics, medications, and referrals, and to support billing for timely payment from insurers and patients.

The role requires knowledge of authorization protocols across health plans, HIPAA compliance, and utilization management. You will collaborate with physicians and office staff to verify medical necessity and determine patient financial responsibility.

Qualifications

• High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs.
• 1 year in a healthcare setting with insurance verification/authorizations can be substituted in lieu of specialized training.
• Knowledge of HIPAA and payer workflows is preferred.

Responsibilities

• Collaborates with physicians and provider staff to determine appropriate authorization based on medical necessity and treatment plan.
• Performs medical necessity checks to verify support for procedures and diagnoses.
• Ensures authorizations align with network policy and communicates any out-of-policy items to appropriate parties.
• Contacts insurance companies to obtain verification, benefits, and precertification for approval.
• Verifies additional clinical information and insurance authorizations/referrals as needed.
• Reviews schedules to ensure proper authorizations have been obtained before patient visits.
• Monitors accounts registered versus scheduled procedures to maintain compliance with benchmarks.
• Determines estimated patient financial responsibility using verification data and payer contracts.

Skills

Billing procedures

Payer reimbursement

HIPAA knowledge

Utilization management

Insurance benefits

Education

High School Diploma/GED with insurance, coding, billing or healthcare certificate programs

Job description

Job Summary:

Obtains benefits and authorizations for surgical procedures, diagnostic testing, medications, outgoing referrals, and other services as part of daily operations. Determines the authorization protocols for each health plan and performs billing duties to ensure proper and timely payment is received from insurance carriers and patients.

Qualifications:

Education:

High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs.

Experience:

1 year in a healthcare setting with insurance verification/authorizations can be substituted in lieu of specialized training.

Skills Needed:

• Familiarity with billing procedures and payer reimbursement.
• Knowledge of patient rights and laws relative to those rights, such as HIPAA.
• Proficient in utilization management processes, standards, and managed care.
• Proficient in standard medical practices and insurance benefit structures

Essential Functions:

• Collaborates with physicians and provider office staff in ascertaining the appropriate authorization based on medical necessity and the treatment plan provided.
• Performs a medical necessity check to determine if procedure and diagnosis support medical necessity.
• Ensures authorizations are obtained in accordance to network policy (any authorization not falling into policy guidelines is communicated to ordering office, patient, and manager).
• Communicates direct/indirect with insurance companies to obtain insurance verification, benefits and precertification for approval.
• Verifies additional clinical information and insurance authorizations/referrals.
• Reviews and monitors WQs/schedules to ensure that proper and accurate authorization has been received prior to patient’s visit.
• Maintains compliance with benchmark data regarding accounts registered versus scheduled procedures.
• Determines estimated patient financial responsibility using insurance verification information and payer contracts and/or self-pay guidelines.
• Takes on other duties as assigned

Benefits:

• Choice of medical, dental, and vision plans with great coverage at VERY affordable rates.
• 403b Retirement Plan with generous company match
• Paid Time Off for holidays, vacation, sick & personal days
• Employee Assistance Program
• Tuition Reimbursement