Eugene, OR
Essential functions
Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.
- Submits, tracks, and follows up on prior authorization requests for medical and ancillary procedures via payer portals, phone, or fax.
- Research and resolves authorization and referral claim denials, while coordinating with physicians, providers, and insurance payers to file appeals or facilitate a P2P.
- Reviews patient medical records and clinical documentation to ensure they meet payer coverage criteria.
- Work with the Prior Authorization Supervisor on policies, procedures, and workflows by providing relevant information and feedback.
- Maintain knowledge of payer guidelines (Medicare, Medicaid, Commercial, etc.) and ensure regulatory compliance.
- Interacts with insurance payers, physicians, providers, and Slocum departments to clarify coverage requirements to expedite approvals.
- Communicate cross-functionally with providers and other Slocum departments regarding patient questions or referral and authorization concerns.
- Perform other duties as assigned.
Competencies
- 1 – 3 years of recent experience as a Prior Authorization Specialist, with expertise in medical billing, healthcare, and the insurance referral process.
- Clear understanding of medical terminology, ICD-10, CPT, and HCPC coding, and insurance payer policies.
- Experience working with Electronic Health Records (NextGen preferred), and payer portals.
- Strong attention to detail (Accuracy in code selection is critical for compliance and reimbursement.
- Familiarity with CMS and insurance payer guidelines and requirements.
- Proficient with Microsoft Office Suites (Outlook, Word, and Excel).
- Possess the ability to prioritize workload daily, weekly and monthly.
- Strong communication, attention to detail, and problem-solving skills.
Supervisory responsibilities
- None
Physical demands
- Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.
- Able to sit or stand for long periods of time.
- Be able to work on a computer and keyboard for up to eight hours a day.
- Able to walk, and use hands to finger, handle, or feel. Able to reach with hands and arms.
- Ability to hear and understand in person and over the phone.
- Able to speak and provide information in person and over the phone.
OSHA Occupational Exposure
This position is designated as a Category 3 employee that does not perform tasks that involve exposure to blood, body fluids, or tissue.
Education and Experience
- Medical insurance knowledge and background required.
- High school diploma or GED or equivalent experience and training required.
- Previous experience as a Prior Authorization and/or Insurance Referral Specialist.
- Previous experience working with Electronic Health Records.
Summary
The RCM Prior Authorization Specialist obtains insurance approvals for medical and ancillary services. Act as a liaison between providers, patients, payers. Verify benefit coverage, submit clinical documentation while striving to maintain a high level of accuracy in submissions. Handle denials and appeals and ensure compliance with insurance payer and regulatory requirements to facilitate timely patient care and ensure payment.