Prior Authorization Specialist- Lead

Position Overview :

The Lead Prior Authorization Specialist is responsible for obtaining benefit coverage information, pre-certification, and pre-authorization for cases referred to A3i and ensuring timely processing of every pre-service review. Lead Specialist will use a combination of internal software tools, Availity, and Payer Portals. Lead- Specialist will leverage medical policy knowledge to interact with Payer for the patient’s benefit.

Primary Job Functions:

• Expert use of Availity and Payer Portals. • Reviews case paperwork and related information that has been entered into the company database system to ensure accuracy. • Reviews clinicals and diagnosis/CPT codes against coverage guidelines as needed, and notifies physician(s) to review coverage policy to determine whether or not they should continue with the procedure. • Creates and maintains timely and accurate notes in the database system detailing all precertification activity related to each case. • Contacts Payer(s) to determine available benefits for requested equipment and/or service; Follows guidelines set by Payer(s) to obtain authorization to supply equipment and/or service. • Ensures adequate phone coverage by logging in and out of the phone queue in a timely manner. • Handles individual case load in accordance with guidelines (i.e. turnaround time) established by the client. • Provides CPT and HCPCS coding support to physicians, as required. • Maintains timely and regular communications with physician’s office regarding the status of pending cases. • Notifies the appropriate team members in a timely manner regarding status of authorizations, so that service/equipment can be provided as needed.

Secondary Job Functions:

• Supports the vision and values of A3i and abides by all A3i policies and procedures. • Understands the product/service line provided by A3i. • Improves and implements procedures as needed and/or assigned. • Consistently provides optimum Customer Service to all internal and external customers. • Consistently works to develop and maintain positive and professional relationships with all internal and external customers. • Required Reads & Training Curriculum as identified. • Performs other duties and projects as assigned.

Education Requirements:

• High school diploma or equivalent is required.

• Associates Degree in Health Care Administration or related field is preferred.

Experience Requirements:

• 5 year of insurance verification and pre-authorization experience in the healthcare industry is preferred. • CPC strongly preferred. • A minimum of 7 years clerical, administrative, or customer service experience in healthcare is required.

Skills/Abilities:

• Expert use of Availity and Payer Portals • Ability to communicate effectively, both orally, and in writing. • Ability to operate within Microsoft Office applications at an intermediate level to include Outlook, Word, MS Excel, and PowerPoint. • Strong customer service skills.

Physical Requirements/Work Environment:

The physical requirements and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must have a secure area at home to work in with a desk and chair. Must have reliable high-speed internet service. While performing the duties of this Job, the employee is regularly required to sit, stand; walk and talk or hear. Some bending, stretching, and stooping are required. Requires sitting for extended periods of time. Manual and visual dexterity sufficient to use a keyboard, monitor and calculator is required. Verbal communication and use of telephone is required. Employee may occasionally be required to lift, push and/or pull up to 20 pounds in weight.