Insurance Verification and Prior Auth Specialist

Ohio Gastroenterology Group•Columbus, OH

7d•Onsite

About The Position

This role is responsible for verifying insurance information, obtaining prior authorizations, and ensuring accurate patient billing. The specialist will interact with insurance carriers, internal departments, physician offices, and patients to manage the pre-certification process, identify patient financial responsibilities, and resolve authorization issues. Key duties include updating patients on their preauthorization status, coordinating peer-to-peer reviews, notifying providers of denials, and maintaining comprehensive knowledge of payer requirements. The role also involves running reports to ensure timely verification, responding to patient inquiries, and collaborating with the Billing Department to prevent claim denials. Secondary functions include attending meetings, maintaining patient confidentiality, and adhering to all relevant laws and company policies.

Requirements

High school diploma or equivalent
Knowledge of third-party payers and prior-authorization requirements
Understanding of basic medical terminology and procedures
Proficient use of office equipment, such as copier and fax machine, phones, etc.
Intermediate computer skills including use of Microsoft Office (Excel and Word), electronic mail, payer websites, physician practice management, and electronic medical records systems.
High attention to detail and the ability to multi-task.
Strong time management skills
Ability to work independently with minimal supervision and to manage multiple priorities.
Strong written and verbal communication skills
Ability to effectively communicate with a variety of people under stressful circumstances.
Neat appearance, professional demeanor and pleasant voice
Fluent in English

Nice To Haves

One (1) year of experience and relevant knowledge of revenue cycle functions, insurance eligibility, or prior authorization in a healthcare setting preferred
Experience with eClinicalWorks a plus

Responsibilities

Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for patients.
Follows up with internal departments, physician offices, patients and third-party payers to complete the pre-certification process.
Identifies out of pocket amounts (i.e., copay, deductible, co-insurance), determining the correct coordination of benefits, identifying if a replacement or supplemental plan exists, identifying termed coverage, and identifying if the patient's plan is considered out of network coverage.
Collaborates with internal departments to provide account status updates, including expected out of pocket amounts, coordinate the resolution of issues, and appeal denied authorizations.
Ensures services have prior authorizations and updates patients on their preauthorization status.
Coordinates peer to peer review if required by insurance.
Notifies ordering providers if authorization/certification is denied.
May need to coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.
Maintains files for referral and insurance information, and enters referrals into the system.
Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
Runs system-generated reports to verify insurance verification/authorization is being done timely prior to the patient's date of service; verifies the insurance benefits and eligibility either by phone or online for every patient that is scheduled.
Responds to patient calls about how out of network insurance is handled and provide patient with letter explaining this if necessary.
May need to respond to patient inquiries about their insurance benefits.
Assists physician’s office staff with any insurance benefit questions and educate them on any changes to the insurance companies’ verification/pre-certification process for the facility.
Ensures insurance information is verified and entered into the billing system.
Works with Billing Department to assure all insurance information is entered so claims are not denied.
May help research any claim issues.
Attend meetings and training sessions.
Maintain confidentiality of patient and financial information by utilizing HIPAA guidelines and regulations.
Adheres to all Federal, State, and Local laws and regulations as well as policies set forth by Ohio Gastroenterology Group Inc and its related parties.