Prior Authorization
4 weeks ago
The role involves handling Prior authorization requests, verifying insurance coverage, ensuring compliance with regulations in the US healthcare system.
This role involves coordinating prior authorization for medical, pharmacy and radiology related services.
The specialist will work collaboratively working closely with physician, insurance providers and internal teams to streamline processes and ensure timely patient care.
The Prior authorization Specialist needs to be able to review and understand Provider Medical Records.
The Prior authorization Specialist needs to be able to submit Appeals for denied claims and ensure all accurate and pertinent information is provided to the Payer in a timely manner.
Key Role: Review and process prior authorization requests for medications, diagnostics, and treatments.
Communicate with insurance companies to obtain approval for medical, pharmacy and Radiology Collaborate with physician, medical assistants, and billing teams to ensure accurate and complete submissions.
Verify insurance benefits and document all authorization details in EMR and other systems.
Monitor and follow up on pending authorizations and escalate issues as needed.
Stay updated on payer guidelines, formularies, and coverage policies.
Maintain confidentiality and compliance with HIPAA regulations at all times.
Qualifications: Experience in Prior Authorization, medical billing and US healthcare administration Minimum 2 to 3 years of Prior Authorization experience in US healthcare Working knowledge of insurance plans, including Medicare, Medicaid, and commercial payers.
Familiarity with medical, pharmacy, radiology and diagnosis codes (ICD/CPT).
Proficiency in healthcare systems and tools such as Google Sheets, Google Docs, EMRs, and payer portals.
Strong communication and documentation skills.
Attention to detail and organizational skills Ability to work independently, prioritize tasks and work efficiently in a remote environment.
Problem solving skills and the ability to resolve authorization related issues There are the types of authorizations we typically work with: Medical: Botox (buy & bill and through specialty pharmacy) - J0586, 64612 Dysport: (buy & bill and through specialty pharmacy) - J0585, 64612 Kenalog (J3301)5 FU (J9190)Bleomycin (37241)Lasers (17106, 17107,17108) Ultrasound Guided Botox (76536) DAO (76536) Excision (Depending on region: 67961, 21013, 61590,14040, 64612, 14301, 15740, etc.)Pharmacy: Botox (through specialty pharmacy)Dysport (through specialty pharmacy)Radiology: MRI/MRA (depending on the region)Ultrasounds (depending on the region 76882, 76881, etc.) CT/CTAEMG/ENOG Audiogram
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