Surgical Authorization Specialist

Austin; Austin, Northern (TX, KY); Hybrid; USD 52,000 - 78,000; Full time

Job summary

Advanced Pain Care is seeking a Surgical Authorization Specialist to verify insurance eligibility, obtain benefits, and ensure pre-certification and referrals are met before services. You will coordinate with payers and clinical partners to document accurate information in the patient record.

The role requires at least three years in billing/pre-authorization or insurance verification, with knowledge of Medicare, Medicaid, HMOs and PPOs, and will involve regular communication with patients and

Qualifications

• Requires a high school diploma or GED.
• Minimum of three years’ experience in billing/pre-authorization or insurance verification.
• Knowledge of Medicare, Medicaid, HMOs and PPOs.

Responsibilities

• Verifies insurance eligibility and benefit levels prior to services.
• Works with payers via electronic, telephonic, and/or fax communication.
• Verifies pre-certification, predetermination, and referral requirements.
• Determines medical necessity with payer policies.
• Communicates with patients and clinical staff to facilitate authorization.
• Submits clean claims and reduces payer denials by following policies.

Skills

Clear communication

Customer relations

Billing terminology

Online insurance portals

Typing skills

Time management

Confidentiality

Education

High school diploma or GED

Tools

None

Job description

Must be local to Austin/ the surrounding area

This position will be remote/ hybrid once training is complete

Surgical Authorization Specialist Job Purpose:

The Surgical Authorization Specialist is a member of the Surgical Auth Department who is responsible for verifying eligibility, obtaining insurance benefits, and ensuring pre-certification, authorization, and referral requirements are met prior to the delivery of outpatient and ancillary services. The Surgical Authorization Specialist provides detailed and timely communication to both payers and clinical partners in order to facilitate compliance with payer contractual requirements and is responsible for documenting the appropriate information in the patient's record. Other duties as assigned.

DUTIES INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING

• 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, predetermination, and referral requirements for services.
• Determines medical necessity by reviewing the appropriate medical policies established for each insurance payer.
• Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
• Communicates with patients, clinical navigators, financial counselors, and others as necessary to facilitate authorization process.
• Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals.
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in electronical medical record.
• Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements.
• 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.
• Operates standard office equipment (e.g. copier, personal computer, fax, etc.).
• Has regular and predictable attendance.
• Adheres to Advanced Pain Care’s Policies and procedures.
• Performs other duties as assigned.

SUPERVISION

Director of Surgical Auth

Requirements

MINIMUM QUALIFICATIIONS

Education

Requires a high school diploma or GED

Experience

Minimum of three years’ experience in billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare, Medicaid, HMO’s and PPO’s required.

WORKING CONDITIONS

Environmental Conditions

Medical Office environment

Physical Conditions

• Must be able to work as scheduled – typically from 8:00 – 5:00 M-F
• Must be able to sit for prolonged periods of time

KNOWLEDGE AND SKILLS:

• Clear and effective communication
• Exceptional customer relations skills required
• Knowledge of billing terminology including CPT codes and ICD-10 codes
• Knowledge of online insurance portals
• Excellent typing and computer skills
• Effectively manages day by organizing and prioritizing
• Applies tactful principles and practices of dealing with the public
• Practices safety habits
• Protects patient information and maintains confidentiality