ELIGIBILITY & AUTHORIZATION SPECIALIST

Job Description

Job Description

JOB SUMMARY:

The Eligibility and Authorization Specialist is responsible for completing monthly patient eligibility and benefits checks to determine patient coverage/responsibility for services including, but not limited to, primarily major medical insurance benefits verification, complex insurance plan verification, and volume PBM plans. The Eligibility and Authorization Specialist needs to understand and work with HCPCS codes (i.e. J & B codes), Diagnosis codes, route of administration, place of service, IPA/HMO claims, Medicare B & D billing, Major Medical, and PBM. The Eligibility and Authorization Specialist will also be responsible for facilitating authorization submittals/follow-ups/appeals for patients with new insurance due to plan changes.

QUALIFICATIONS:

• High School Diploma or attainment of a GED through an accredited institution. Two years of college education preferred.
• 1-3 years of insurance verification and/or pharmacy tech experience in using HCPCS billing codes, diagnosis codes, route of administration, place of service, IPA claims, Medicare B&D billing, Major Medical, PBM, authorization; OR experience as an Insurance Verifier or similar position with Home Infusion or Specialty Pharmacy.
• Experience with Waystar and familiarity with EMS (Eligibility Management Systems), preferred.
• Familiarity with the 270-transaction process, including how to request eligibility and benefits information through EDI, preferred.
• 1-3 years of experience in obtaining prior authorizations.
• 1-3 years of experience with the coordination of benefits, secondary insurance and/ or patient assistance programs.
• Knowledge of and ability to explain concepts of medical benefit plan design (cost benefit, co-insurance, lifetime benefit, out-of-pocket maximum, using billing codes. CPT codes, and Diagnosis codes/ route of admin /place of service).
• At least 2 years of experience in providing customer service to internal and external customers, including meeting quality standards for services, and evaluation of customer satisfaction.
• Problem-solving experience.
• Experience working with out-of-network insurance plans and handling appeals processes is strongly preferred.
• Must have excellent verbal and written communication skills.
• Must be flexible and open to work outside of normal business hours based on department needs.
• Computer proficiency in standard office applications, i.e. Microsoft Office Suite applications (Word, Excel, PowerPoint, Outlook); ability to learn and master industry specific software applications.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Verify and validate all insurance benefits for patients by contacting insurance providers via phone, online portals (e.g. Waystar, NaviNet, Optum), and other communication channels.
• Obtain and document detailed information on coverage, copayments, deductibles, and any other relevant insurance details.
• Monitor all referrals throughout the insurance verification process before deadlines.
• Document, track, and monitor plan terminations and conversion requirement changes.
• Collaborates with healthcare providers to gather necessary information for authorization submissions.
• Collaborates with stakeholders regarding discharge planning process for patients with no authorization as applicable.
• Prepare and submit authorization requests to insurance companies, ensuring that all required documentation is accurate and complete.
• Completing submissions in a timely manner
• Consistently follow up with the plans on authorization status and communicate back to internal teams.
• Handle incoming and outgoing calls from internal team members, account managers, insurance payers and clinics related to insurance benefits.
• Effectively communicate with patients, healthcare providers, and insurance companies to address inquiries and provide clarification on benefit verification and authorization processes.
• Collaborating across departments (i.e. Intake, Billing) to escalate and resolve complex issues.
• Keep the leadership team abreast of any payor issues as it relates to authorization and benefits coverage.
• Work with clinical staff regarding appeal issues.
• Prepare and submit appeal requests to insurance companies, ensuring that all required documentation is complete and accurate.
• Other duties as assigned.