Prior Authorization Associate I

Abbott•Madison, WI

3d•$15 - $30•Remote

About The Position

The Prior Authorization Associate I is responsible for all aspects of the prior authorization process and works cross-functionally with sales, operations, billing, laboratory, and reimbursement operations teams to serve patient and client needs. The role determines initial and ongoing eligibility and coverage, assesses whether prior authorization is needed for reimbursement, identifies process deficiencies, assists with triage, documents actions in systems, and manages accounts in dedicated daily work queues. It supports appropriate coverage review using Epic, external portals, and other software, and communicates relevant information to ancillary departments and other teams. The position also works insurance eligibility and claim issues, researches accounts, reviews claims and appeals, follows up with payors, resolves denials and underpayments, and ensures accurate and timely documentation and write-offs in accordance with applicable policies and regulations. Work is remote in the United States, with a standard Monday–Friday schedule of 8 a.m.–5 p.m. The role includes approximately 5% travel and requires working at a computer and/or typing for about 90% of a typical workday.

Requirements

High school diploma or General Education Degree (GED).
At least 2 years of direct experience submitting and following up on prior authorization workflows.
At least 3 years of experience in medical billing, claims, and/or insurance processing.
Extensive and current working knowledge of government, managed care, and commercial insurance claim submission requirements, reimbursement guidelines, and denial reason codes.
Knowledge of medical terminology and/or health insurance terms.
Knowledge of EHR operating systems and experience working with electronic records.
Proficiency with computer systems and keyboarding.
Demonstrated attention to detail and focus on quality output.
Ability to perform the essential duties with or without accommodation.
Authorization to work in the United States without sponsorship.
Ability to complete a high volume of prior authorization requests.
Ability to work at a computer screen and/or type for approximately 90% of a typical workday, and use a computer and phone simultaneously.
Ability to work Monday through Friday during normal business hours.
Ability to complete the Epic-process assessment with a score of 80% or higher.

Nice To Haves

Related associate degree or medical billing certification.
At least 5 years of experience in medical, laboratory, or insurance billing fields.
Experience with Epic or another EHR application.

Responsibilities

Determine initial and ongoing patient insurance eligibility and verify, investigate, and correct accounts in Epic, including patient demographics, financial information, and guarantor information.
Interact with insurers and third-party payors to obtain and document authorizations accurately and promptly in accordance with internal and external policies and regulations.
Research missing or incorrect account information using portals and other resources, including outreach to identify unknown payors.
Review and edit claims and appeals before submitting them to a clearinghouse.
Analyze, research, and resolve claim issues using applicable federal, state, and payor rules and procedures.
Monitor work queues for claims requiring research and take actions to move them toward resolution.
Provide CRM support and work Claim Edit and Follow Up work queues.
Use Onbase to work documents specific to the TOQ department.
Correct claims rejected by the claim scrubber, clearinghouse, or payor.
Review explanations of payment and denials, identify resolution steps, and take appropriate action, including appeals, write-offs, or sending statements.
Validate new workflows resulting from product growth and own designated work queues until setup is validated as effective.
Investigate payor underpayments and follow up with payors by phone on unpaid aging claims.
Provide supporting documentation requested by insurance payors.
Complete accurate and timely write-offs for uncollectible accounts in accordance with policies and guidelines.
Provide ad hoc departmental support, including special projects and support during outages or high-volume periods.
Complete responsibilities within required time frames while meeting quality standards.
Stay current with medical billing regulations, rules, and guidelines, and comply with HIPAA confidentiality requirements.
Communicate effectively with staff at all levels and work cooperatively in a team environment.
Work independently, adapt to changing workloads and information, and complete assigned tasks reliably and on time.
Maintain professionalism in interactions with team members, clients, and associates.
Complete a required assessment of understanding of Exact Sciences Epic processes with a score of at least 80%.
Support and comply with company Quality Management System policies and procedures, and maintain regular and reliable attendance.
Work a normal Monday–Friday schedule during normal business hours.
Use a computer and phone simultaneously and use a telephone through a headset.