Prior Authorization Specialist (Referral Specialist & Insurance Elg)

Roles and Responsibilities

• Verify patient eligibility, benefits, and insurance coverage through phone calls or electronic verification methods.
  
• Obtain prior authorizations from healthcare providers for medical services rendered by out-of-network providers.
  
• Handle denial management by resolving issues related to claims rejection and ensuring timely resolution of discrepancies.
  
• Utilize CPT codes to identify billing errors and optimize revenue cycle management processes.
  
• Manage referrals effectively by coordinating with referring physicians, hospitals, and other stakeholders.
  

Desired Candidate Profile

• 1-5 years of experience in Prior Authorization, Eligibility Verification, Insurance Verification, Denial Management, or Revenue Cycle Management.
  
• Strong understanding of ICD-10-CM/PCS coding system.
  
• Excellent communication skills for effective interaction with patients' families and healthcare providers.

• Direct experience with radiology and infusion prior authorizations is required.
• Experience managing prior authorizations from benefit verification through approval, denial, or appeal.
• Experience working with commercial insurance, Medicare Advantage, and Medicaid managed care plans.
• Strong understanding of authorization requirements for imaging and infusion services.
• Prior experience in healthcare RCM, prior authorization, referral coordination, or insurance operations.
• Experience handling GLP-1 or specialty medication prior authorizations.
• Experience communicating directly with insurance carriers, physician offices, specialist offices, and patients.

• Familiarity with common ophthalmology CPT codes and documentation requirements for eye care authorizations.
• Experience supporting a U.S.-based healthcare practice in a remote or dedicated capacity.
• Experience coordinating peer-to-peer reviews.
• Experience preparing and submitting payer appeals for denied authorizations.

Strong understanding of ophthalmology revenue cycle workflows.