Senior Process Specialist

Summary:

The Senior Authorization/Pre-Estimate Collection Agent is responsible for securing required authorizations and pre-estimates for healthcare services prior to service delivery and ensuring the collection of patient financial responsibilities related to those pre-estimates. This role requires in-depth knowledge of insurance verification, authorization processes, pre-estimate calculation, and patient communication strategies. The Senior Agent handles complex cases, provides guidance to junior team members, and plays a key role in optimizing upfront collections and minimizing denials.

Essential Duties and Responsibilities:

Authorization Management:

Verify patient insurance coverage and benefits to determine authorization requirements for planned services.

Obtain necessary authorizations from insurance payers in a timely manner, using online portals, phone calls, and other methods.

Document all authorization activities accurately and thoroughly in the billing system.

Follow up on pending authorization requests and resolve any issues or delays.

Communicate authorization status to patients, providers, and other relevant parties.

Appeal authorization denials and follow up on pending appeals.

Stay current on changes in payer authorization policies and procedures.

Pre-Estimate Collection:

Calculate accurate patient out-of-pocket expenses (co-pays, deductibles, co-insurance) based on insurance benefits and planned services.

Communicate pre-estimate information to patients in a clear and understandable manner.

Collect patient financial responsibility (or establish payment plans) prior to service delivery.

Document all pre-estimate and collection activities accurately in the billing system.

Address patient questions and concerns regarding pre-estimates and payment options.

Reconcile pre-collected amounts with actual charges after service delivery.

Work with billing and collections teams to resolve any discrepancies.

Understanding of HIPAA regulations and ensure compliance in all activities.

Stay current on changes in payer regulations, coding guidelines, and billing requirements

Problem Solving and Analysis:

Identify trends in authorization denials or pre-estimate collection challenges and propose solutions.

Work with other departments (e.g., scheduling, registration, billing) to improve pre-service processes.

Research and resolve complex authorization or pre-estimate inquiries from patients and insurance companies.

Mentorship and Training:

Serve as a mentor and resource for junior Authorization/Pre-Estimate Collection Agents.

Assist in training new team members on authorization procedures, pre-estimate calculation, and collection techniques.

Provide guidance on handling difficult or complex cases.

Reporting and Process Improvement:

Prepare regular reports on authorization rates, pre-estimate collection rates, and key performance indicators (KPIs).

Identify opportunities to improve pre-service processes and increase efficiency.

Participate in team meetings and contribute to process improvement initiatives.

System Proficiency:

Utilize billing software, insurance verification systems, and other relevant tools to manage authorizations and pre-estimates (e.g., EPIC, Availity, etc.).

Maintain accurate and up-to-date information in all systems.

Qualifications, Experience & Skills:

Undergraduate degree or equivalent required; associate or bachelors degree in a related field preferred.

Minimum of 5-7 years of experience in Patient Access, medical authorization, Prior Auth and/or pre-estimate collection.

Proven track record of successfully obtaining authorizations and collecting patient financial responsibility upfront.

Experience working with various insurance payers (e.g., Medicare, Medicaid, Commercial).

In-depth knowledge of insurance verification and authorization processes.

Strong understanding of medical billing

Excellent communication and interpersonal skills, especially in explaining financial information to patients.

Strong analytical and problem-solving abilities.

Proficiency in using billing software and Microsoft Office Suite.

Ability to work independently and as part of a team.

Excellent organizational and time-management skills.

Ability to handle a high volume of cases and meet deadlines.