Patient Benefits Specialist / Prior Authorization Specialist

Position Summary

The Patient Benefits Specialist is responsible to obtain pre-authorizations/pre-certifications as required by insurers for upcoming procedures, special testing, and referrals, and contacts patients prior to services to discuss insurance coverage and financial responsibility.

Essential Job Functions and Responsibilities

• Obtains pre-authorizations/pre-certifications as required by health insurers or managed care providers for upcoming procedures, radiology or diagnostic testing, laboratory or other special testing.
• Works with reception and clinical staff to coordinate referrals to outside facilities or providers.
• Verifies Medicare, Medicaid and health insurance eligibility prior to upcoming services and procedures.
• Contacts patients prior to appointment or procedure to discuss insurance coverage and benefits and patient financial responsibility.
• Informs Patient Account Representatives of new or different insurance plans for patients, in case claims need to be resubmitted to the correct payer.
• Works with clinical staff to manage appointment frequency, insurance coverage and benefits for patients on infusion therapy.
• Maintains up-to-date knowledge of clinical guidelines, precertification requirements, and medical policies for services and procedures by routinely reviewing payer newsletters, regulatory and payer websites, and professional periodicals.
• Acts as administrator for the insurance websites and obtains and maintains logon access to all payers' websites.
• Performs other duties as assigned.

Minimum Qualifications

• Education
  • High school diploma or equivalent required.
• Licensure/Certification
  • Advanced training/certification in medical billing, coding, and/or insurance preferred.
• Experience
  • Minimum of one-year experience in a medical billing role is required, or equivalent education.

Competencies Required

• Knowledge
  • Working knowledge of medical and insurance terminology.
  • Basic knowledge of medical and insurance terminology, CPT, HCPCS, and ICD-10 coding.
• Skills
  • Possesses interpersonal, communication, and listening skills necessary to deal effectively and courteously with patients and all staff members.
  • Proficient computer skills working in an Electronic Medical Record (EMR) and Practice Management software, and Microsoft Word, Excel, and the Internet.
  • Demonstrates professionalism and respect in all forms of communication and correspondence.
• Abilities
  • Ability to maintain strict confidentiality of fiscal and health information.
  • Ability to work in a fast paced, multi-tasking environment and cope with rapidly changing demands while working as a team member.
  • Ability to prepare and gather information accurately and efficiently.