Pre-Authorization and Insurance Specialist

WESTERN WAYNE FAMILY HEALTH CENTERS•Dearborn, MI

11d•Onsite

About The Position

The Pre-Authorization and Insurance Specialist verifies insurance eligibility, benefits, treatment history, and coverage requirements for dental procedures. The role processes and coordinates referrals and coverage determinations, serving as a liaison among dental providers, dental assistants, billing staff, patients, insurance entities, and collaborating facilities. Duties also include administrative and clerical work such as communicating with insurance entities, scheduling or rescheduling appointments, and reviewing treatment plans for coverage and frequency limitations. The specialist reviews treatment plans, diagnostic codes, and treatment history; confirms eligibility, benefits, and provider credentialing; and ensures required notes and documentation are complete before submission. The role prepares and submits referrals, prior authorizations, pretreatment estimates, precertifications, and predetermination requests, follows up on approvals, denials, and appeals, and communicates determination details to patients and care teams. The specialist tracks requests and expirations, maintains determination records in the EHR and tracking logs, documents in accordance with established standards, and protects patient information under HIPAA. The position also responds to calls and voicemails, prepares forms for provider review and signature, cross-trains with front desk and billing teams, and performs additional duties as directed by dental or management staff. This is a full-time, day-shift position located at Western Wayne Dearborn in Dearborn, Michigan. The role requires a high school diploma and two years of experience in a dental support role or in a healthcare setting as a certified dental biller, pre-authorization specialist, or insurance coordinator.

Requirements

High school diploma.
Two years of experience in a dental support role, or experience as a certified dental biller, pre-authorization specialist, or insurance coordinator in a healthcare setting.
Knowledge of insurance verification and authorization processes for dental services.
Understanding of payer guidelines and frequency limitations.
Strong analytical skills to review benefit coverage and identify payer-specific requirements.
Proficiency creating, using, and maintaining electronic health records.
Ability to communicate effectively with patients and staff to resolve insurance-related issues.
Ability to develop and maintain effective relationships with vendors and providers.
Ability to understand and handle the sensitivity and confidentiality of patient information.
Understanding of medical terminology.
Valid driver’s license.
Adherence to confidentiality and HIPAA policies.
Ability to work in a complex work environment.
Ability to maintain confidentiality and organizationally appropriate relationships.
Knowledge of organization policies and procedures.
Knowledge of computers, systems, and applications.
Initiative, sound judgment, problem-solving, and decision-making skills.
Ability to develop and maintain effective relationships with patients, customers, and other staff.

Responsibilities

Review treatment plans, diagnostic codes, and treatment history before submission.
Verify insurance eligibility, benefits, and frequency limitations before submission and scheduling procedures.
Select the appropriate insurance plans in the Electronic Health Record (EHR).
Review the requesting provider’s credentialing status for the service location before submission.
Ensure dental notes and required documentation are complete and submitted to insurance entities in a timely manner.
Prepare and submit referrals, prior authorizations, pretreatment estimates, precertifications, and predetermination requests to insurance entities and collaborating facilities, ensuring information and attachments are accurate and complete.
Contact insurance entities to confirm approval requirements are met and forward determination details to the requesting location and provider.
Schedule STAT, urgent, and high-risk referrals and ensure timely follow-up and documentation.
Reschedule cancelled, missed, or no-show appointments.
Monitor, track, and update requests and expirations to prevent coverage gaps or delays in care.
Maintain accurate, current records of determinations in tracking logs and the EHR.
Follow up on denials and appeal submissions in coordination with billing staff.
Identify and resolve discrepancies and problems as they arise.
Contact patients about insurance determinations and help ensure they understand their treatment plans and benefits.
Communicate and collaborate with providers, dental assistants, billing staff, and other department staff to meet and document authorization requirements.
Respond promptly to calls and voicemails about pending determinations or benefit inquiries.
Prepare forms for provider review and signature.
Document determination status in the EHR, including IDentalSoft, Athena, or EPIC.
Use EHR systems as the official medical record, follow documentation standards, and maintain Protected Health Information confidentiality in accordance with HIPAA.
Adhere to Western Wayne Family Health Centers policies and procedures.
Demonstrate strong interpersonal and time-management skills.
Cross-train with front desk and billing teams to understand related workflows and provide backup when needed.
Perform additional functions as directed by dental or management staff.