Specialist

Job Description

Responsibilities

Prior Authorization & Benefits Verification

• Review incoming orders to verify completeness and accuracy of documentation required for prior authorization submission.
• Initiate and manage prior authorization requests in accordance with payer requirements and medical policies.
• Work directly with vendors, payers, and insurance representatives to facilitate successful prior authorization submissions.
• Monitor prior authorization request status, track pending cases, and perform follow-up activities to support timely determinations.
• Review insurance policies, medical policies, and payer guidelines to ensure authorization requests meet applicable requirements.
• Perform benefit investigations to support reimbursement and pre-billing activities.

Billing Inquiry Support

• Respond to billing-related inquiries received through phone, email, chat, portal, and other communication channels.
• Provide prior authorization status updates and requirements information to providers, patients, and insurance representatives.
• Support resolution of authorization-related and billing-related issues.

Documentation & Operational Support

• Maintain accurate records of prior authorization requests, approvals, denials, and related activities within designated databases and systems.
• Enter and maintain authorization, coverage, and benefits information in applicable platforms.
• Identify process improvement opportunities related to authorization and reimbursement workflows.
• Participate in projects and initiatives supporting operational improvements and business objectives.
• Maintain productivity and service-level expectations while managing assigned work schedules and changing business priorities.

Minimum Qualifications

• Requires a High School or equivalent with minimum 2 years’ relevant experience.  Successful completion of the training sessions including Medical Terminology, Anatomy and Physiology along with passing the assessment of skill.

Preferred Qualifications

• Associate degree in Healthcare Administration, Business Administration, Health Information Management, or a healthcare-related field.
• 1 or more years of experience in Clinical Laboratory Revenue Cycle Management (RCM) operations.
• 1 or more years of experience supporting prior authorization, reimbursement, billing, or benefits verification activities within a clinical laboratory environment.
• 1 or more years of experience using Microsoft Word, Microsoft Excel, and Microsoft Outlook in a healthcare reimbursement, billing, authorization, or revenue cycle environment.

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