Prior Authorization and Verification

Prior Authorization, Verification and Eligibility

Location: Bridgetowne, Quezon City
Work Setup: Onsite
Schedule: Night Shift

We are looking for an experienced Account Specialist team under Patient Access – Benefits & Authorization.

Key Responsibilities:

• Supervise daily operations involving insurance verification, benefits review, package registration, referrals, authorization support, and patient financial responsibility workflows.
• Monitor team productivity, quality, turnaround times, and service levels.
• Serve as a subject matter expert on payer requirements, eligibility tools, benefit interpretation, referrals, authorizations, network status, and provider participation.
• Review team documentation to ensure accuracy and compliance with established standards.
• Provide coaching, training, feedback, and performance development to team members.
• Handle escalated patient, provider, payer, and internal inquiries.
• Collaborate with Front Office, Clinical, Contact Center, Revenue Cycle, and leadership teams to resolve issues and improve workflows.
• Support staffing coordination, workload balancing, process improvement, and quality assurance initiatives.
• Prepare and communicate operational and performance reports to leadership.
• Ensure compliance with departmental policies, payer requirements, privacy standards, and applicable regulations.

Qualifications:

• High School Diploma or equivalent required; Associate's or Bachelor's degree in Healthcare Administration, Business, or a related field is preferred.
• At least 3–5 years of experience in Patient Access, Insurance Verification, Benefits, Referrals, Authorizations, Revenue Cycle, physician office, or hospital environments.
• Strong knowledge of insurance verification, benefit interpretation, prior authorization, referral processes, payer requirements, and patient financial responsibility.
• Familiarity with CPT, ICD-10, medical terminology, clinical documentation, and payer medical necessity guidelines.
• Proficiency in EHR systems, eligibility tools, pre-certification platforms, payer portals, Microsoft Office, and reporting tools.
• Strong leadership, communication, organizational, analytical, problem-solving, coaching, and conflict-resolution skills.
• Ability to manage workloads, analyze trends, identify root causes, and implement workflow improvements.
• Orthopedic experience is strongly preferred