Prior Authorization Specialist

Job Description

Networks Connect is looking for a Prior Authorization Specialist that will work in office. Networks Connect is seeking a dedicated and detail-oriented Prior Authorizations Specialist to join our Client’s, a local prominent health system, Patient Access team. This role is instrumental in navigating insurance payor regulations to enhance patient access to care and improve financial outcomes for inpatient, ambulatory, and physician practice settings. As a subject matter expert on payor requirements, authorizations, and appeals, you will work closely with referring physician offices, payors, and patients to ensure a seamless care experience.

Key Responsibilities:

Pre-Service Payor Clearance

• Navigate payor coordination of benefits (COB) issues to ensure timely claims payments.
• Obtain pre-authorizations and referrals, ensuring all are on file before services are rendered.
• Pre-register patients, verify insurance eligibility and benefits, and communicate patient financial responsibilities.
• Collaborate with internal departments to ensure scheduled patients meet all payor clearance requirements.
• Provide clinical information to payors, reducing the need for peer-to-peer reviews.

Patient Navigation and Notification

• Act as a liaison to address custodial or legal issues prior to patient arrival.
• Interpret insurance verification information to estimate and communicate patient financial responsibility.
• Advocate for patients by addressing barriers to care and facilitating communication with the Financial Information Center.
• Compare and communicate in-network and out-of-network benefits to patients.

Revenue Cycle Outcomes

• Review and ensure clinical documentation supports insurance requirements to minimize claim denials.
• Write appeal letters and collaborate with departments to address first-pass denials and root causes.
• Measure improvements in service line outcomes, including reducing delays and rescheduled services.
• Maintain detailed records of authorizations and appeal outcomes, providing monthly reports to track trends.

Qualifications:

Education

• High School Diploma or GED (Required).

Experience

• Minimum of 3 years of experience in healthcare payor navigation, insurance referral and authorization processes, and appeals (Required).
• At least 2 years of experience with CPT and ICD coding assignments (Required).

Skills and Knowledge

• Strong interpersonal, verbal, and customer service skills with professional etiquette.
• Knowledge of insurance guidelines for government and private carriers.
• Familiarity with electronic medical records (EMRs) and healthcare software, including Cerner and Passport (Preferred).
• Attention to detail, ability to multitask, and problem-solving skills.
• Bilingual abilities (Preferred).
• Successful completion of all Patient Access training assessments.

Core Competencies

• Customer Service: Anticipate and respond to patient and physician office needs.
• Problem-Solving: Identify and implement solutions to improve administrative processes.
• Teamwork: Collaborate with departments to achieve organizational goals.
• Safety: Promote a safe environment by adhering to policies and demonstrating clear communication.
• Cost Management: Efficiently use resources and identify cost-saving opportunities.

Why Join Us?

This role offers the opportunity to make a meaningful impact in patient access and care navigation. If you are passionate about helping patients and thrive in a collaborative, fast-paced healthcare environment, we encourage you to apply.

Job Type: Full-time

Pay: $50,000.00 – $65,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Professional development assistance
• Retirement plan
• Vision insurance

Work Location: In person

Earnings

$20-$24 hourly

Category

Revenue Cycle