Prior Authorization Associate I

Abbott•Madison, WI

1d•Remote

About The Position

The Prior Authorization Associate I is responsible for all aspects of the prior authorization process, including determining initial and ongoing patient eligibility and coverage, assessing whether authorization is needed for reimbursement, and handling a high volume of authorization requests. The role works cross-functionally with sales, operations, billing, laboratory, and reimbursement operations teams to support patients and clients. It identifies deficiencies, triages issues, documents actions in relevant systems, and manages accounts in assigned work queues. The role uses Epic, external portals, Onbase, and other software to verify coverage, resolve account and claim issues, and communicate applicable information to other teams. The position works remotely in the United States on a standard first shift, Monday through Friday, from 8 a.m. to 5 p.m. Travel is listed as 5% of the time. The role requires prolonged computer and keyboard use and simultaneous computer and phone work. The base pay is $14.85–$29.65 per hour, with variation possible in specific locations.

Requirements

High school diploma or GED.
At least 2 years directly involved in submission and follow-up of 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 independently, remain focused, and complete assigned work reliably and on time.
Ability to adapt to changing workloads and circumstances and respond quickly to new information.
Ability to communicate effectively in writing and verbally and work cooperatively in a team.
Ability to work at a computer and type for approximately 90% of the workday, use a computer and phone simultaneously, and use a phone headset.
Successful completion of an Exact Sciences 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 or ongoing patient insurance eligibility, investigate accounts, and correct patient demographics, financial information, and guarantor information in Epic.
Interact with insurers and third-party payors to obtain and document authorizations accurately and promptly in accordance with policies and regulations.
Research missing or incorrect account information using portals and other resources, including identifying unknown payors and conducting outreach.
Review and edit claims and appeals before submission to a clearinghouse.
Research and resolve claim issues in accordance with federal, state, and payor rules and procedures.
Monitor work queues, research claims, and take action to move them toward resolution.
Provide CRM support and work Claim Edit and Follow Up work queues.
Use Onbase to process documents specific to the TOQ department.
Correct claims rejected by claim scrubbers, clearinghouses, or payors.
Review explanations of payment and denials, determine next steps, and appeal, write off, or send statements as appropriate.
Validate new workflows arising from product growth and own assigned work queues until setup is confirmed to be effective.
Investigate payor underpayments and follow up with payors by phone regarding unpaid aging claims.
Provide supporting documentation requested by insurance payors.
Complete accurate and timely write-offs of uncollectible accounts in accordance with policies and guidelines.
Provide ad hoc departmental support, including special projects and assistance during outages or high-volume periods.
Complete responsibilities within required time frames and quality standards, and stay current with medical billing regulations, rules, and guidelines.
Maintain confidentiality and comply with HIPAA requirements and the company’s Quality Management System policies and procedures.
Complete an assessment of understanding of Exact Sciences Epic processes with a score of at least 80%.
Maintain regular and reliable attendance and work the normal Monday-through-Friday business schedule.
Work at a computer and/or type for approximately 90% of a typical workday, use a computer and phone simultaneously, and use a telephone through a headset.
Communicate effectively with staff at all levels, work cooperatively in a team, adapt to changing workloads, and conduct interactions professionally.
Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork.