Prior Authorization Specialist

Keystone Advisors LLC•Matteson, IL

10d

About The Position

Keystone Advisors is seeking a Prior Authorization Specialist to join its team in Matteson, Illinois, supporting a healthcare client. The specialist obtains and processes prior authorization requests and coordinates calls, data entry, and tracking related to insurance-provider and health-plan authorizations, expedited reviews, and appeals. The role requires documenting and tracking communications with insurers and health plans, following up on denials, and helping ensure services are validated. The specialist reviews accounts, initiates pre-authorizations and other managed-care requirements, collects demographic, insurance, and clinical information, and ensures reimbursement requirements are met. The position communicates with patients, referring physicians, staff, referral sources, insurance companies, and medical providers; supports medical-necessity documentation and authorization appeals; and records required authorization documentation in patient records. The role also monitors utilization, identifies reimbursement trends and errors, and maintains knowledge of insurer and billing authorization requirements.

Requirements

High school diploma or GED equivalent with five years of prior authorization experience, or a bachelor's degree with two years of prior authorization experience.
Three years of experience processing insurance requests to obtain prior authorization.
Experience and familiarity with insurance portals, such as Anthem, Availity, Evicore, CoverMyMeds, and Magellan.
Proficiency with Microsoft applications and internet-based programs.
Strong interpersonal skills and ability to establish strong working relationships.
Excellent verbal and written communication skills for communicating with staff at all levels and a patient population comprising diverse cultures and age groups.
Strong time-management skills to prioritize assignments and meet deadlines.
Ability to anticipate, recognize, and meet the needs of patients and their families.
Ability to work in a team-based environment to accomplish goals and objectives.
Ability to demonstrate respect and sensitivity toward cultural diversity in the client's workforce and patient population.
Ability to think critically, solve problems, and make independent decisions supporting the authorization process, including interactions with payer representatives, physicians, and hospital case managers.

Nice To Haves

Knowledge of and experience with payer processes for submitting appropriate clinical documentation.
Experience using medical terminology.

Responsibilities

Review accounts and initiate pre-authorizations and other managed-care requirements, routing cases to appropriate departments as needed.
Collect demographic, insurance, and clinical information to ensure reimbursement requirements are met.
Notify necessary parties within required timeframes for routine and urgent service requests.
Assist in monitoring utilization services to promote cost-effective use of medical resources through prior authorization processing.
Communicate with patients and referring physicians about non-covered benefits or procedure-coverage issues.
Assist with medical-necessity documentation to expedite approvals and ensure appropriate follow-up.
Provide consistent and comprehensive written and verbal information to facilitate approvals.
Ensure insurance-carrier documentation requirements are met and authorization documentation is entered and recorded in patient records.
Appeal pre-authorization denials and/or set up peer-to-peer reviews.
Maintain working knowledge of insurance companies and billing authorization requirements.
Identify and report undesirable trends, reimbursement-modeling errors, and underlying causes of incorrect payment; review allowed variances from third-party payers.
Build and maintain working relationships with staff, referral sources, insurance companies, and medical providers.
Document and track communication attempts with insurance providers and health plans, and follow up on denials.