Job Overview
The prior authorization specialist /receptionist is a dual role in which they are responsible for managing all work related to drug authorizations for all injectable drug treatment plans ordered by our providers using knowledge of payer coverage policies and applies appropriate payer guidelines to all aspects of drug prior authorization work. Additionally, the successful candidate will answer calls and schedule patients as needed.

The Prior Authorization Specialist creates accurate, thorough, and concise prior authorization requests to all payers. Reviews and monitors the drug authorization work queue and independently identifies and prioritizes patient treatment/therapy plans that require prior authorization.

Duties

Reprioritizes work to respond to clinically urgent treatment and therapy plans and produces high quality work under pressure.
· Verifies insurance eligibility and benefits, utilizing automated eligibility systems, payer portals, and/or telephone communication.
· Assists patients with resolving insurance related issues prior to initiating treatment.
· Prepares and completes payer-specific prior authorization request forms, interprets medical policy criteria, and applies appropriate guidelines to prior authorization requests.
· Responds to health plan-reviewed prior authorization requests that do not meet initial policy criteria. Works with the health plan to resolve issues and/or coordinates appropriate provider-to-health plan interventions (e.g., peer-to-peer discussions, letters of medical necessity, provider-initiated appeals, etc.).
· Manages prior authorization reports to ensure appropriate drug dispenses are appropriately authorized and followed-up on.
· Monitors and reports changes in payer prior authorization requirements to update and maintain prior authorization tools and spreadsheets.
· Completes appropriate post-claim denial follow-up to overturn drug-related prior authorization claim denials.
· Maintains digital archiving of prior authorizations to support post-claim denial workflows.
· Assists with the training of new staff and performs other work duties and projects as assigned.
· Performs other duties as assigned.
· Answer and place telephone calls in a prompt and professional manner, directing calls as needed and recording messages.
· Greet and register patients in a timely and professional manner, ensuring completion of necessary forms and validation of information.
· Enter or verify patient information in the PM/EMR software and educate patients on their insurance coverage.
· Verify patient information prior to evaluations and explain benefits, billing processes, and outpatient policies.
· Collect patient co-payments and fees, documenting transactions and preparing daily bank deposits.
· Track and obtain ongoing insurance verification and authorization information from payers.

Skills

Proficient in managed care principles and practices.
Experience in a medical office setting or dental office required.
Strong understanding of HIPAA regulations regarding patient privacy.
Familiarity with CPT coding, ICD-9, ICD-10, and general ICD coding practices.
Knowledge of medical terminology essential for effective communication.
Ability to efficiently handle insurance verification processes.
Excellent organizational skills with attention to detail in managing medical records.
Strong interpersonal skills for effective collaboration with healthcare professionals and patients. Join our dedicated team as a Prior Authorization Specialist where you can make a meaningful impact on patient care while utilizing your expertise in the healthcare field.

Job Type: Full-time

Expected hours: 40 per week

Benefits:

401(k)
Dental insurance
Health insurance
Paid time off

Work Location: In person

Janigian Retina Associates

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Prior Authorization Specialist/Medical Reception