Job Description

Eligibility and Authorization Specialist

Position Summary:

The primary function of the Eligibility and Authorization Specialist is to contact medical insurance carriers to ensure eligibility, prior authorization and/or obtain referrals for all clinical services . Identifies outstanding patient financial responsibility by creating financial estimates and notifying patients. This position is responsible for processing the financial clearance of each patient and ensuring successful payment of services rendered .

Reports To: Eligibility and Authorization Specialist Coordinator

Principal Duties and Responsibilities

1. Responsible for effective and efficient verification and authorizations of all patients’ benefits.

2. Utilization of electronic verification/eligibility technology or contacting insurance companies to verify and/or obtain patient eligibility and benefits.

3. Verify existing patient insurance coverage and update the information in the practice management software system.

4. Responsible for obtaining all referrals and authorizations for procedures and services, as required.

5. Responsible for acting as a liaison between patients, healthcare providers, and insurance carriers to ensure all proper measures are taken and information is collected.

6. Address rejected claims related to patient eligibility, authorization, or demographics.

7. Responsible for answering incoming calls from other providers, recipients, and carrier groups in relation to insurance coverage.

8. Ensures all patient questions are answered and issues are resolved timely by utilizing the appropriate resources.

9. Develops and maintains effective relationships with the patients ensuring all patient demographic and insurance information is obtained and current.

10. Maintain up-to-date knowledge of specific clinical services, registration, and pre-registration requirements for all departments.

11. Maintain awareness of federal and state health care legislation and regulations, OSHA, and HIPAA.

12. Proactively identifies and leads department process improvement opportunities.

Required Skills, Knowledge, and Abilities:

• Excellent organizational skills and the ability to multi-task.

• Ability to operate basic office equipment, answer multi-line telephones, and have a strong computer background.

• Establish and maintain effective working relationships with patients, insurance companies, and staff.

• Strong written and oral communication skills.

• Knowledge and skills in working with computerized billing systems including practice management software and EMR.

• Must adhere to all HIPAA guidelines and regulations.

• Knowledge of medical insurance and authorization processes

• Knowledge of medical terminology and experience working in a healthcare or insurance environment.

• Knowledge of organizational policies, procedures, and systems.

• Ability to document electronically and accurately.

• Use appropriate guidelines for releasing information.

Education

High school diploma or equivalent

Experience

• 2 years of experience performing insurance verification or working with medical insurance programs.
• Experience with eligibility, verification of benefits, and prior authorizations from various HMOs, PPOs, commercial payers, and other funding sources.

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