Orthopedic Prior Authorization Specialist

Description

The Prior Authorization Specialist is responsible for ensuring that all necessary authorizations are obtained for procedures and treatments. This role involves close collaboration with physicians, patients, insurance companies, and other healthcare professionals to ensure timely and accurate processing of prior authorization requests. The initial focus of this role will be on orthopedics and procedures involving implants. 

Supervisory Responsibilities:

Not Applicable 

Duties and Responsibilities:

Prior Authorization Processing: 

• Review medical records, treatment plans, and insurance policies to determine the need for prior authorization for orthopedic procedures. 
• Submit prior authorization requests to insurance companies and follow up on approvals or denials. 
• Ensure all required documentation is complete and submitted to insurance providers promptly. 

Communication: 

• Act as a liaison between patients, healthcare providers, and insurance companies to facilitate the prior authorization process. 
• Communicate authorization statuses, denials, and appeals processes to patients and healthcare providers. 
• Provide patients with information regarding their insurance benefits and coverage for orthopedic services. 

Documentation and Record-Keeping: 

• Maintain accurate and detailed records of all prior authorization requests, approvals, denials, and communications. 
• Ensure compliance with all federal, state, and local regulations, including HIPAA. 

Insurance Verification: 

• Verify patient insurance coverage and benefits for orthopedic services. 
• Identify and resolve any discrepancies in coverage before the procedure or treatment is scheduled. 

Denials and Appeals Management: 

• Manage and process denied claims by working with healthcare providers and insurance companies to gather additional information or appeal decisions. 
• Track and follow up on appeals to ensure timely resolution. 

Collaboration: 

• Work closely with the billing department to ensure accurate coding and billing for authorized services. 
• Collaborate with the OR and scheduling team to stay informed about upcoming procedures and necessary authorizations.  

Requirements

• Strong understanding of orthopedic procedures and terminology. 
• Knowledge of insurance policies, medical coding (CPT, ICD-10), and the prior authorization process. 
• Excellent communication and interpersonal skills. 
• Detail-oriented with strong organizational skills. 
• Proficient in medical billing software and electronic health records (EHR) systems. 

Education and Experience:

• High school diploma or equivalent required; Associate’s or Bachelor’s degree in healthcare administration or a related field preferred. 
• Minimum of 2 years of experience in prior authorization, medical billing, or a related field, preferably within an orthopedic setting. 
• Experience with insurance verification and prior authorization process 
• Certified Professional Coder (CPC) or similar certification is a plus. 
• Certified Orthopedic Technologist (OTC) is advantageous. 

ADA Job Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Physical Demands: Prolonged periods sitting at a desk and working on a computer.   

Communication Skills: Writing, speaking, hearing, reading, interpersonal relationships, receiving instructions, giving instructions.   

Intellectual Skills: Short and long term memory, abstract reasoning, decision making, directing others, mathematical calculations.   

Work Situations: Working as part of a group, working with the public, performing a variety of duties.   

Disclaimer: 

This job description indicates the general nature and level of work expected of the incumbent. It is designed to cover or contain a comprehensive listing of activities, but not all-inclusive, listing of activities, duties or responsibilities required of the incumbent. Incumbent may be asked to perform other duties as required. See ADA checklist for specific related criteria.