Eligibility and Prior Authorization Specialist

Eligibility and Prior Authorization Specialist will be responsible for building and maintaining collaborative and productive relationships with internal and external stakeholders relating to eligibility and prior authorization, driving performance in operations related to reimbursement and providing direction and oversight of processes impacting cash collections.

PRIMARY RESPONSIBILITIES:

• Serves as a source of knowledge for the designated revenue cycle function.
• Performs analysis, identifies trends, presents opportunity areas, and prioritizes initiatives for performance improvement for the designated revenue cycle function.
• Establishes an ongoing working relationship with other departments impacting revenue cycle performance.
• Works closely with various vendor operations teams (Prior authorization, Claims and Appeals) to oversee operations activity that directly impacts the revenue cycle to accurately process actions in a timely manner for optimal reimbursement.
• By continually reviewing and monitoring eligibility and prior authorization changes, researches, evaluates, and interprets guidance from a variety of sources to determine departmental actions.
• Coordinates with Management to ensure thorough understanding of trends/issues affecting revenue cycle performance.
• Develops goals and metrics to link department and revenue cycle initiatives with the organization’s strategy.
• Develops, manages, and monitors successful completion of implementation and project plans.
• Continuously seeks new and creative technologies that help identify and guide improvement opportunities that align with overall company success.

Required Knowledge, Skills, and Abilities:

• Proficiency with medical billing systems, Microsoft Excel, medical terminology, and basic procedure coding knowledge.
• Knowledge of medical terminology and abbreviations, and healthcare nomenclature and systems.
• Strong communication (verbal and written), organizational, problem-solving, and team player skills.
• Ability to navigate across multiple customer demands and balance competing priorities successfully.
• Ability to analyze, identify, and articulate identified trends and report trends succinctly in a clear and concise manner.
• Ability to solve problems using critical thinking skills.
• Maintains confidentiality of sensitive information.
• Analytical skills required.
• Ability to think critically and identify the impact across the revenue cycle with a solution-oriented approach.
• Ability to develop, implement, and produce analysis and reports.

Qualifications:

• At least 3 years of experience in medical billing and insurance collections.
• At least 3 years of experience with eligibility and prior authorization requirements, payer utilization management policies, and appeals.
• Knowledge of CPT/HCPCS, ICD-10, modifier selection, and UB revenue codes.
• Bachelor’s Degree in a healthcare-related field of study or equivalent experience.