Pre Authorization Representative-Full Time

About the Role:

The Pre-Certification and Authorization Rep is responsible for performing all insurance precertification and authorization requirements for patients scheduled for services in an Orthopedic practice. This includes validating demographic information and insurance eligibility coverage to ensure financial clearance and that services are cleared to be performed prior to the date of service.

• Verify patient’s insurance benefits for all in-office procedures, treatments, including HA injections, MRI, EMG’s, and Surgical procedures
• Notifies insurance companies of services being rendered, and obtains any necessary authorizations, ensuring notification and verification is complete for each order.
• Obtains and verifies any necessary additional demographic and/or billing information.
• Actively obtains authorization for referrals same day as ordered by physicians.
• Coordinate with provider’s offices and medical staff to ensure all necessary documentation is obtained for purposes of pursuing a successful authorization approval.
• Accurately records all actions, interactions, and authorizations surrounding the insurance process for each patient into the Electronic Medical Record (EMR) system
• Researching and appealing denied authorization, including setting up Peer to peer calls and Appeals
• Provides quality customer service to all patients promptly and have professional communication.
• Additional experience in WC/No Fault claims.
• Other duties as assigned.

ADDITIONAL RESPONSIBILITES:

• Work as a team member within the patient services department and all other departments.
• Must be able to recognize and respond appropriately to urgent/emergent situations.
• Establish and maintain effective working relationships.
• Effectively cope with typical job stress.
• Document work processes as required
• Education, Certification, Computer and Training Requirements
• High school graduate/GED required
• 1–2-year experience required
• Ability to communicate in English, both Orally and in writing required
• Accurate computer data entry skills required
• Knowledge of CPT and ICD-10 coding
• Knowledge of medical office and terminology preferred
• Experience with standard office equipment (Phone, fax, copy machine, scanner, email/voice mail) preferred
• Experience with standard office technology in a Window based environment preferred.
• Review and process pre-authorization requests for medical services and procedures.
• Communicate with healthcare providers to obtain necessary documentation and information.
• Interact with insurance companies to verify coverage and obtain approvals.
• Maintain accurate records of all pre-authorization requests and their outcomes.
• Provide timely updates to patients and healthcare providers regarding the status of pre-authorization requests.

Skills:

The required skills for this role include strong communication abilities, which are essential for effectively liaising with healthcare providers and insurance representatives. Attention to detail is crucial, as the representative must accurately gather and document information to ensure successful pre-authorization. Organizational skills are also important, as the representative will manage multiple requests simultaneously and must prioritize tasks efficiently. Preferred skills, such as familiarity with EHR systems, enhance the representative's ability to access and input patient information quickly. Overall, a combination of these skills enables the Pre Authorization Representative to streamline the pre-authorization process and improve patient care outcomes.