Prior Authorization Specialist

Southwest Spine And Pain Care Specialists Llc; St. George (VT); On-site; USD 42,000 - 64,000; Full time

Job summary

Southwest Spine And Pain Care Specialists Llc is seeking a healthcare coordinator to manage prior authorization workflows. You will answer calls, collect and enter data, review clinical information for approvals, and coordinate with physicians and insurers to secure scheduling and coverage.

The role emphasizes customer service, accuracy, and timely processing. Ideal candidates have at least six months of prior authorization experience, familiarity with CPT/ICD-10, and strong communication skills

Qualifications

• Six months of prior authorization experience or training supplied.
• Knowledge of CPT and ICD-10 coding.
• Familiarity with medical terminology.
• High School education or GED.
• Ability to interact with patients, insurers and office staff professionally.

Responsibilities

• Answer calls from patients and physician offices with exemplary customer service.
• Enter required information into the computer system accurately.
• Review clinical data against medical criteria for authorization review.
• Check orders for insurance coverage and pre-certification needs.
• Obtain missing documentation from physicians or offices.
• Coordinate with insurers to pre-certify/authorize procedures as ordered.
• Communicate updates to ordering physicians if denied and assist with peer-to-peer reviews as needed.
• Monitor pre-cert status to ensure timely processing and completion.
• Log orders and schedule procedures upon approval.

Skills

CPT/ICD-10 codes

Medical terminology

Accurate data entry

Communication with patients/insurers

EMR/database entry

Teamwork

Prior authorization experience

Education

High School Diploma or GED

Job description

Essential Functions/Responsibilities:Answer calls from patients and physician offices using exemplary customer service skills.Accurately enter required information, non-clinical and clinical, into computer database.Review clinical data matching it against specified medical criteria and follow established procedures for authorizing request for further review.Review incoming orders for completeness to determine if procedure ordered will be covered by insurance (in some cases, pre-certification is not warranted).Complete follow-up with physicians for orders still waiting for documentation.Contact physicians offices to obtain missing documentation to complete orders.Works with patients insurance companies to pre-certify/authorize procedures as ordered by the referring physician.Contact ordering physician with update if procedure is denied and assist with scheduling peer to peer reviews, if needed.Once order is complete, contact patient to confirm receipt of order and inform patient he/she will receive a scheduling call once insurance has been approved.Monitor pre-certification status to ensure timely processing and completion.Log order into the appropriate authorization spreadsheet and schedule procedure once approved.Maintain patient confidentiality as defined by state, federal and company regulations.Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.Actively support departmental and corporate strategic plans and ensure successful implementation.Maintain cooperative working relationships with all clinics and providers.Qualifications:Six months of previous experience in medical prior authorization. Will train the right personKnowledge of CPT and ICD-10 codes.Familiarity with medical terminology.High School Education or GED.Ability to interact with patients, insurers, and office team members in a responsible, professional, and ethical manner.Must be able to function effectively in a team-oriented environment.Must be able to work independently with limited direction.Must be reliable and demonstrate sound judgment and initiative.Able to work in a high volume/fast-paced environment.