Pre-Auth Executive

7 months ago

Mumbai, India Bizmatics India Private Limited Full time

-Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt, pt estimation calculation
-Successfully works with payers via electronic/telephonic and/or fax communications.
-Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services.
-Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits.
-Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
-Communicates with clinical partners, financial counselors(Pt estimation), and others as necessary to facilitate authorization process.
-Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals.
-Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in both the Auth/Cert and Referral Shells.
-Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements.
-Ensures timely and accurate insurance authorizations are in place prior to services being rendered.
-Follows departmental policies and procedures when necessary authorization is not obtained prior to service date.
-Answers provider, staff(prognocis messages), and patient (email from CM, PFS) questions surrounding insurance authorization requirements.
-Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations.
-Communicate any insurance changes or trends among team.
-Clearly document all communications and contacts with providers and personnel in standardized documentation requirements, including proper format.
-Denial management, finding trends/Medical policies benefical for pre-auth process/Identify and report trends and prior authorization issues relating to billing and reimbursement.
-Performs other related duties as required or assigned.

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