Authorization Specialist SSC

externallincarecareers; Nashville (TN); On-site; USD 42,000 - 62,000; Full time

Job summary

externallincarecareers is seeking a Prior Authorization Specialist to manage end-to-end prior authorizations, communicating with patients, doctors, and insurers to ensure compliant documentation.

The role focuses on triaging requests, handling approvals and denials, and maintaining accurate records while using AS400 and LITE within HIPAA guidelines.

Qualifications

• High School Diploma or equivalent (GED) required.
• Experience with prior authorizations is beneficial.

Responsibilities

• Prioritize incoming prior authorization requests.
• Evaluate and triage prior authorization rejections to determine validity of the prior authorization.
• Communicate with patients regarding clinical information to be used when submitting the prior authorization.
• Review patient chart documentation to ensure accuracy of prior authorization submissions.
• Request, track, and obtain prior authorization from insurance carriers within time allotted for medical services using my meds, fax, or verbal communication.
• Follow up on submitted authorizations with insurance carriers when no response is received.
• Initiate appeals for denied authorizations when justified.
• Maintain patient files on Prior Authorizations tracker.
• Compose letters for various situations including medical necessity and appeal letters.
• Use ICD-10 diagnosis codes accurately in submission of prior authorizations.
• Contact patients via the platform to update status of prior authorization.
• Assist patients with medication assistance programs, including signatures from providers and tracking progress.
• Demonstrate and apply knowledge of medical terminology and HIPAA regulations.
• Communicate with pharmacies/insurance carriers via phone, fax, or written communication.
• Maintain productivity and document all communications in standardized format.
• Evaluate options and make efficient decisions; maintain accurate records.
• Proficiency with multiple programs including internet and email; learn new software such as AS400 and LITE.

Skills

HIPAA regulations

Medical terminology

Communication

Education

High School Diploma or GED

Tools

AS400

LITE

Job description

This employee verifies insurance, obtaining authorizations and documents needed to confirm order; responsible for communicating directly with the patient, doctors' offices, insurance companies, and centers associated with the patient's account.

Job Responsibilities:

• Prioritize incoming prior authorization requests
• Evaluate and triage prior authorization rejections to determine validity of the prior authorization
• Communicate as needed with patients regarding clinical information to be used when submitting the prior authorization
• Review patient chart documentation to ensure accuracy of prior authorization submissions
• Request, track, and obtain prior authorization from insurance carriers within time allotted for medical and services using my meds, fax, or verbal communication
• In a timely manner, follow up on prior authorizations that have been submitted with no response from the insurance carrier
• When justifiable, initiate appeals for denied authorizations
• Maintain patient files on Prior Authorizations tracker
• Compose letters for various situations to include medical necessity letters and appeal letters
• Use ICD-10 diagnosis codes accurately and properly in the submission of prior authorizations
• Contact patients via the platform to update the status of their prior authorization
• Assist patients with medication assistance programs to include obtaining signatures from providers, submit documentation to medical assistance programs, and tracking progress
• Demonstrate and apply knowledge of medical terminology
  • high proficiency of general medical office procedures including HIPAA regulations
• Communicate with pharmacies/insurance carriers via phone, fax, or written communication
• Maintain a level of productivity suitable for the department
• Clearly document all communications and contacts with providers and personnel in standardized documentation requirements, including proper format

• Evaluate options and make efficient decisions
• Maintain consistently accurate records
• Proficiency with multiple programs that include the use of internet and email
• Learn how to use new software
  • AS400
  • LITE

Education and Experience:

• High School Diploma or equivalent (GED) required

Physical Demands:

The employee may frequently lift and/or move up to 10 pounds and may occasionally lift and/or move up to 25 pounds.