Prior Auth Specialist

Poppy Bank; Phoenix (AZ); On-site; USD 52,000 - 70,000; Full time

Job summary

Poppy Bank is seeking a Prior Authorization Specialist in Phoenix to verify insurance eligibility and benefits, coordinate with payers, and support the authorization workflow. You will gather documentation, contact clients for missing items, and submit prior authorization requests to payors to enable testing and services.

You will interact with patients and clinical partners, escalate when needed, and maintain accurate records in the authorization systems to ensure smooth patient care and timely

Qualifications

• Verifies insurance eligibility and benefit levels prior to services.
• Interacts with payers via electronic, telephonic, and/or fax communications.
• Verifies pre-certification, authorization, and referral requirements for services.

Responsibilities

• Verifies insurance eligibility and benefits before services.
• Works with payers via electronic/telephonic/fax communications.
• Verifies pre-certification, authorization, and referral requirements.
• Provides information to payers, including medical necessity when needed.
• Collaborates with clinical contacts for escalations to peer review.
• Communicates with patients, partners, and financial counselors to facilitate authorization.
• Prioritizes workload to handle urgent cases promptly.
• Completes accurate documentation in Auth/Cert and Referral Shells.
• Determines Medicare primacy per Federal guidelines.
• Determines inpatient Medicare coverage and hospice entitlement.
• Ensures timely insurance authorizations before services.
• Adheres to departmental policies when authorization is pending.
• Responds to provider, staff, and patient questions about authorization requirements.

Skills

Insurance verification

Communication skills

Documentation

Prioritization

Education

High school degree

Job description

• Location 9520 West Palm Lane,Suite 150-A,Phoenix, AZ, 85037,United States
• Job Category Prior Authorization, CPT, Insurance Verification
• Employee Type Full Time-Non-Exempt
• Required Degree High school
• Manage Others No

Description

Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt. Successfully works with payers via electronic/telephonic and/or fax communications. Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services.

Requirements

• Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services before receipt.
• Successfully works with payers via electronic/telephonic and/or fax communications.
• Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services.
• Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.
• Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
• Communicates with patients, clinical partners, financial counselors, and others as necessary to facilitate the authorization process.
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
• Completes accurate documentation in both the Auth/Cert and Referral Shells.
• Determines Medicare primacy based on Federal guidelines.
• Determines inpatient Medicare coverage for days exhausted and hospice entitlement.
• Ensures timely and accurate insurance authorizations are in place prior to services being rendered.
• Follows departmental policies and procedures, when necessary, authorization is not obtained prior to service date.
• Answers provider, staff, and patient questions surrounding insurance authorization requirements.
• Other duties as required.

Summary

The Prior Authorization Specialist is responsible for all aspects of the prior authorization process. Responsibilities include collecting all the necessary documentation, contacting the client for additional information, and completing the required prior authorization to proceed with testing. Complete, timely, and accurate identification and submission of prior and retro authorization requests to the payors. Interacts with clients, insurance companies, patients, and sales representatives, as necessary, to request prior authorizations. Provides the highest level of customer service to internal and external clients.