Prior Authorization Representative – Retina
About The Position
The Prior Authorization and Patient Liaison for Retina is responsible for managing all prior authorizations and copay assistance applications related to intravitreal injections and retina-specific medications. This role serves as a key point of contact for patients, guiding them through treatment, insurance processes, and financial assistance options. Responsibilities include verifying eligibility, coordinating with payers, enrolling patients in financial assistance programs, and ensuring timely approvals to avoid treatment delays. This position supports multiple providers across locations and plays a critical role in maintaining efficient patient flow within a high-volume retina practice.
Requirements
- 2+ years in a medical office setting
- Strong knowledge of insurance verification, prior authorizations and specialty drug coverage
- Understanding of CPT/ICD-10 and HCPCA coding
- Strong analytical, problem-solving, and organizational skills
- Excellent written and verbal communication skills
Nice To Haves
- Ophthalmology or retina experience strongly preferred
- Proficiency in EMR/PM systems (experience with ModMed a plus)
- Knowledge of HIPAA and patient privacy standards
Responsibilities
- Serve as a primary point of contact for retina patients, guiding them through treatment plans, insurance processes, and financial assistance options
- Review retina clinic schedules to identify patients requiring prior authorizations
- Verify insurance eligibility and benefit details for injectable medications and procedures
- Obtain all necessary prior authorizations for retina injections, ensuring accurate ICD-10, CPT, and HCPCS coding
- Submit supporting clinical documentation, including notes, diagnostics, and test results, to facilitate approvals
- Track, follow up on, and document all pending and retro-authorization requests to prevent treatment delays
- Maintain accurate logs of prior authorization statuses, expiration dates, and coverage limitations
- Communicate with Medicare and commercial payers to resolve issues related to authorization delays or denials
- Appeal denied authorizations as appropriate
- Coordinate and apply for manufacturer-sponsored copay or patient assistance programs for eligible patients
- Discuss treatment-related costs, payment options, and financial assistance programs with patients
- Collaborate with providers to communicate coverage-based medication options for retina treatments
- Collaborate with retina technicians and schedulers to ensure patients are cleared for treatment
- Ensure all prior authorization and financial assistance outcomes are accurately documented in the EMR/PM system
- Upload and maintain updated insurance and authorization documentation
- Assist with insurance verification and accurate plan entry when discrepancies are identified
- Respond to patient and clinic inquiries regarding billing, coverage, and assistance programs
- Maintain current knowledge of payer-specific rules for specialty drugs and retina procedures
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
11-50 employees
