Prior Authorization Specialist

ELM Management Services•Atlanta, GA

About The Position

At ELM Management Services, the Prior Authorization Specialist plays a crucial role in ensuring that patients receive the necessary approvals and benefits before their scheduled outpatient services. This position involves close collaboration with physicians and staff to navigate the process of obtaining prior authorization. By securing these authorizations in advance, the specialist helps streamline the patient’s experience and ensures that they can receive the care they need without delays. Reporting directly to the ASC Administrator, this role holds significant responsibility in managing the administrative aspects of outpatient care and facilitating smooth interactions between healthcare providers, patients, and insurance providers.

Requirements

Ability to use discretion and work independently under general supervision
Ability to understand and adhere to the Professional Code of Conduct
Minimum of one year healthcare experience
Must meet pre-employment requirements and maintain all applicable state and job-related guidelines for background screening.
Depending on state-specific requirements, this may include drug testing, health screening, CPR/Basic First Aid, and license/credential verifications

Responsibilities

Maintains responsibility for all outpatient authorization processes
Confirms insurance verification, insurance eligibility, benefits, and network status for all services
Ensures accurate ICD, CPT codes and related medical records are submitted in the authorization request
Follows up on delayed or denied authorization requests and escalates for resolution
Acts as a liaison between the payer and clinic schedulers/medical support staff
Maintains confidentiality of patient information, in accordance with company policy and HIPPA regulations
Creates referrals accurately
Creates detailed documentation and maintains/stores the authorization paper/electronic trail
May work to resolve claims denials related to the prior authorization
Demonstrates ability to tactfully handle difficult situations
Documents thorough explanatory notes on patient accounts, concerning any non-routine circumstances, clarifying special billing processes
Understands the outpatient scheduling process, front-end to back-end
Assists physicians and office staff to expedite scheduling
Answers incoming phone calls and follows through with requests made by patients and staff personnel
Attempts to collect the estimated self-pay balance of all outpatient services/accounts, at the earliest possible collection control point
Identifies those patients without adequate insurance coverage and makes contact with the patient or guarantor to determine guarantors’ ability to pay non-covered charges, if applicable
Contacts scheduled patients to obtain pre-service information, explain financial policies, estimates, balances, and obtain a promise to pay on or before services are rendered
Documents concise and understandable notes regarding all accounts collection activity, as well as each patient or guarantor interaction
Maintains quality and safety in accordance with company policy and HIPPA regulations.
Observes work hours and provides proper notice of absences, tardiness, or work schedule changes
Maintains courteous and cooperative working relationships with management, patients, physicians, other professional contacts, and the public
Presents a well-groomed and professional image
Maintains a working knowledge of available information system capabilities and performs all system applications that are required
Consistently demonstrates the ability to organize work, recognizes and establishes appropriate work priorities, and completes work in a productive manner, without creating backlog
Demonstrates a high-level of customer service skills
Maintains proficiency in data entry skills
Provides feedback to management concerning integrity issues
Perform other work-related duties as requested/directed by management
Completes annual mandatory training as required