Westfield Plastic Surgery Center is looking for a Pre-Authorization Specialist to add to our growing team. The right candidate will be responsible for prior-authorization of hospital surgical and ancillary services. Primary functions include: insurance eligibility verification, benefit and out of pocket liability determinations, pre-determination and pre-certification / authorization of surgeries and/or other clinical services performed at Westfield Plastic Surgery Center. Coordinates with surgical centers and hospitals to schedule surgeries. Work closely with our team in living out our mission statement in a professional manner while working to exceed patient's expectations.
- Maintains excellent communication and positive rapport with all points of contact both internally and externally, documenting pertinent discussions and details of correspondence in all applicable systems to provide tracking and point of reference.
- Responsible for obtaining and communicating accurate benefit information and eligibility, pre-determination/pre-authorization as well as detailed benefit and patient liabilities per insurance company requirements and established timeframes, i.e., online vs. telephone to ensure credible coverage and benefits are in place.
- Responsible for monitoring incoming additions, revisions, and cancellations as well as clinical requests for authorization and benefit identification.
- Scheduling surgical procedure in-office, with outpatient ambulatory surgical centers and hospitals. Self-motivated to work surgical cases and identifying any need to contact patient to obtain additional registration or demographic information, as well as determining any change to authorization and/or coverage requirements.
- Routinely monitors cases pending or not yet started/complete. Being attentive to payer specific processing time frames or clinical documentation needs.
- Initiates expedited reviews with payers when necessary to ensure authorization is in place prior to, or at the time of service and communicates late notifications or risk of no auth situations to Office manager as soon as identified.
- Identifies and takes steps to ascertain and provide necessary clinical documentation to meet payer requests as needed for authorization or pre-determination needs.
- Responsible for data entry of documentation on patient accounts in the computer system, including completion of a surgery booking sheet, and all forms included in the surgical booking process.
- Communicates in a positive and professional manner with the patient / guarantor on any financial issues, including notification of money owed day of service for in-office procedures.
- Meets productivity and quality standards, following all documentation guidelines as communicated by Westfield Plastic Surgery Center.
- Other Duties: This job description incorporates the essential functions and duties required for this position. However, other duties may be required and assigned at times and as determined by the office manager in order to meet the needs of Westfield Plastic Surgery Center.
- High school diploma or equivalent.
- Minimum of 2 years’ experience working in a hospital or clinic billing environment, preferably focused on preauthorization, preferred.
- Knowledge of insurance terms and reimbursement procedures.
- Must be detail oriented.
- Knowledge of Explanation of Benefits (EOB), preferred.
- Excellent verbal and written communication skills required.
- Excellent telephone etiquette.