Prior Authorization Representative – Retina

Eyesight Ophthalmic Services•Somersworth, NH

68d

About The Position

The Prior Authorization Representative for Retina is responsible for managing all prior authorizations and copay assistance applications related to intravitreal injections and retina-specific medications. This includes verifying eligibility, coordinating with payers, enrolling patients in financial assistance programs, and ensuring timely approvals to avoid treatment delays. Core Behavioral Values CLEAR ID: Collaborate, Learn, Empathy, Accountable, Respect, Integrity, Dedication These behaviors are based on Eyesight’s culture and values critical to support the organization’s mission of providing uncompromising care to patients.

Requirements

2+ years in a medical office setting
Strong knowledge of insurance verification, prior authorizations and specialty drug coverage – ophthalmology or retina experience strongly preferred
Understanding of CPT/ICD-10 and HCPCA coding
Strong analytical, problem-solving, and organizational skills
Excellent written and verbal communication skills

Nice To Haves

Proficiency in EMR/PM systems (experience with ModMed a plus)
Knowledge of HIPAA and patient privacy standards

Responsibilities

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 appropriate ICD-10, CPT, and HCPCS codes are submitted
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
Maintain accurate logs of prior authorization statuses, expiration dates, and coverage limitations
Coordinate and apply for manufacturer-sponsored copay or patient assistance programs for eligible patients
Confirm that all prior authorization and financial assistance outcomes are documented in the PM/EMR system
Upload and maintain updated insurance and authorization documentation
Collaborate with retina technicians and schedulers to ensure patients are cleared for treatment
Communicate with payors to resolve issues related to delays or denials.
Appeal denied authorizations as appropriate
Maintain current knowledge of payer-specific rules for specialty drugs and retina procedures
Assist with insurance verification and accurate plan entry when discrepancies are found
Support patients during checkout, especially for financial discussions related to treatment plans
Answer clinic and patient questions related to billing, coverage, and assistance programs