Insurance Verification and Prior Auth Specialist

Ohio Gastroenterology Group, Inc.; Columbus (OH); On-site; USD 36,000 - 54,000; Full time

Job summary

Ohio Gastroenterology Group, Inc. is seeking an Insurance Verification and Prior Auth Specialist to verify patient coverage, obtain pre-authorizations, and coordinate with billing and scheduling to ensure timely approvals.

The role requires knowledge of Medicare, Medicaid, and third-party payer rules, with experience in revenue cycle tasks and eClinicalWorks preferred. The applicant should have a high school diploma or equivalent and strong communication skills to assist patients and internal

Qualifications

• Knowledge of Medicare, Medicaid and third-party payer requirements
• Experience with revenue cycle functions including eligibility and prior authorization preferred
• Understanding medical terminology and procedures
• Proficient in Microsoft Office and payer portals

Responsibilities

• Verify insurance benefits and eligibility prior to service
• Obtain and document preauthorizations and certifications
• Coordinate with scheduling, physicians and billing to ensure timely approvals
• Enter and maintain accurate insurance data in the billing system
• Respond to patient inquiries about coverage and out-of-pocket costs
• Assist staff with changes to insurance verification and pre-certification processes

Skills

Insurance verification

Prior authorization

Medicare/Medicaid knowledge

Communication skills

Education

High school diploma or equivalent

Tools

eClinicalWorks

Job description

Insurance Verification and Prior Auth Specialist

• Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
• Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for patients. Follows up with internal departments, physician offices, patients and third-party payers to complete the pre-certification process.
• Identifies out of pocket amounts (i.e., copay, deductible, co-insurance), determining the correct coordination of benefits, identifying if a replacement or supplemental plan exists, identifying termed coverage, and identifying if the patient\'s plan is considered out of network coverage.
• Collaborates with internal departments to provide account status updates, including expected out of pocket amounts, coordinate the resolution of issues, and appeal denied authorizations.
• Ensures services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance. Notifies ordering providers if authorization/certification is denied.
• May need to coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.
• Maintains files for referral and insurance information, and enters referrals into the system.
• Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
• Runs system-generated reports to verify insurance verification/authorization is being done timely prior to the patient\'s date of service; verifies the insurance benefits and eligibility either by phone or online for every patient that is scheduled
• Responds to patient calls about how out of network insurance is handled and provide patient with letter explaining this if necessary.
• May need to respond to patient inquiries about their insurance benefits.
• Assists physician’s office staff with any insurance benefit questions and educate them on any changes to the insurance companies’ verification/pre-certification process for the facility.
• Ensures insurance information is verified and entered into the billing system.
• Works with Billing Department to assure all insurance information is entered so claims are not denied. May help research any claim issues.
• Other duties as assigned.

Secondary Job Functions:

• Attend meetings and training sessions
• Maintain confidentiality of patient and financial information by utilizing HIPAA guidelines and regulations
• Adheres to all Federal, State, and Local laws and regulations as well as policies set forth by Ohio Gastroenterology Group Inc and its related parties

Knowledge, Skills and Abilities

• Knowledge of third-party payers and prior-authorization requirements
• Understanding of basic medical terminology and procedures
• Proficient use of office equipment, such as copier and fax machine, phones, etc.
• Intermediate computer skills including use of Microsoft Office (Excel and Word), electronic mail, payer websites, physician practice management, and electronic medical records systems.
• High attention to detail and the ability to multi-task.
• Ability to work independently with minimal supervision and to manage multiple priorities.
• Strong written and verbal communication skills
• Ability to effectively communicate with a variety of people under stressful circumstances.
• Neat appearance, professional demeanor and pleasant voice

Credentials and Experience

• Must have high school diploma or equivalent
• One (1) year of experience and relevant knowledge of revenue cycle functions, insurance eligibility, or prior authorization in a healthcare setting preferred
• Experience with eClinicalWorks a plus

Physical Demands

• Must be able to bend over (frequent), climb stairs (frequent), sit (frequent), stand (frequent), stoop (frequent), walk (frequent) and type on keyboard (frequent).
• Minimal medical office exposure that may require contact with adult patients
• Office workstation environment with numerous employees

[1] Critical features of this job are described under this heading. They may be subject to change at any time due to reasonable accommodation or other reasons,

Equal Opportunity Employer
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