Precertification/Eligibility Specialist

JOB SUMMARY

The Precertification and Eligibility Specialist is primarily responsible for obtaining pre-authorizations for high-cost services and therapeutics ordered by Urology San Antonio Providers. This position also serves as a safety net for ensuring insurance benefits for patients are verified prior to receiving services at Urology San Antonio.

DUTIES AND ESSENTIAL JOB FUNCTIONS

• Completes and submits any forms and clinical documentation required to secure appropriate preauthorization(s) and insurance benefit(s) for scheduled services.

• Enters comments in the EMR (eCommunications) that are clear and concise so that the clinic(s) know the coverage dates and any policy limits, deductibles, and co-pays, etc. that may need to be communicated with patients.

• Ensures authorization number is properly documented in EMR necessary for accurate and timely claims submission to the respective insurance payers.

• Prepares Letter(s) of Medical Necessity and paperwork required for submitting appeals by insurance(s) to overturn denials for lack of authorization and /or lack of medical necessity, as needed.

• Sets up Peer-to-Peer reviews between physician and insurance carrier when prior authorization is denied, if necessary.

• Ensures proper insurance payer plan is documented in the patient management system.

• Performs eligibility verification by managing Batch Eligibility process assignments, accessing respective payer websites and calling insurances directly.

• Works claim rejections for eligibility timely to ensure claims are processed to the correct insurance payer.

• Interacts with patients when eligibility and benefits cannot be verified through the various payer portals, etc.

• Obtains prepayment(s)/payment arrangement(s) for patients receiving cancer therapy and other services as appropriate.

• Performs other duties as assigned.

Other functions and Responsibilities

This job description covers or contains a comprehensive listing of most activities, duties, or responsibilities required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

COMPETENCIES

• Patient & Customer Focus
• Ethical Conduct
• Flexibility
• Initiative
• Personal Effectiveness/Credibility

• Stress Management/Composure

• Ability to use MS Office programs within the scope of responsibilities and tasks.

• Multitask and coordinate multiple projects and assignments simultaneously and completing assigned tasks accurately and on a timely basis

• Ability to adapt in a continually changing environment and the ability to work under tight deadlines

• Strong attention to detail and organizational skills

• Excellent written and verbal communication skills

• Ability to work well independently

• Maintain confidentiality

QUALIFICATIONS

Required

• High School Diploma or GED

• 2 years of experience with obtaining preauthorization’s and/or benefits verifications in a medical office or hospital setting

• Proficient knowledge of CPT/HCPCS and ICD-10 codes

• Knowledge of insurance(s) preauthorization requirements

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Weekly day range:

• Monday to Friday
• No weekends

Work Location: In person