Pre-Cert​/Eligibility Specialist

Job Summary

The Precertification/Eligibility Specialist is primarily responsible for obtaining pre-authorizations for high-cost services and therapeutics ordered by Urology San Antonio Providers. This position also serves as a safety net for ensuring insurance benefits for patients are verified prior to receiving services at Urology San Antonio.

• Completes and submits any forms and clinical documentation required to secure appropriate preauthorization(s) and insurance benefit(s) for scheduled services.
• Enters comments in the EMR (eCommunications) that are clear and concise so that the clinic(s) know the coverage dates and any policy limits, deductibles, and co-pays, etc. that may need to be communicated with patients.
• Ensures authorization number is properly documented in EMR necessary for accurate and timely claims submission to the respective insurance payers.
• Prepares Letter(s) of Medical Necessity and paperwork required for submitting appeals by insurance(s) to overturn denials for lack of authorization and/or lack of medical necessity, as needed.
• Sets up Peer-to-Peer reviews between physician and insurance carrier when prior authorization is denied, if necessary.
• Ensures proper insurance payer plan is documented in patient management system.
• Performs eligibility verification by managing Batch Eligibility process assignments, accessing respective payer websites and/or calling insurances directly.
• Works claim rejections for eligibility timely to ensure claims are processed to the correct insurance payer.
• Interacts with patients when eligibility and benefits cannot be verified through the various payer portals, etc.
• Obtains prepayment(s)/payment arrangement(s) for patients receiving cancer therapy and other services as appropriate.
• Performs other duties as assigned.

This job description covers or contains a comprehensive listing of most activities, duties, or responsibilities required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

• Patient & Customer Focus
• Ethical Conduct Flexibility
• Initiative
• Personal Effectiveness/Credibility
• Stress Management/Composure
• Ability to use MS Office programs within the scope of responsibilities and tasks.
• Multitask and coordinate multiple projects and assignments simultaneously and completing assigned tasks accurately and on a timely basis
• Ability to adapt in a continually changing environment and the ability to work under tight deadlines
• Strong attention to detail and organizational skills
• Excellent written and verbal communication skills
• Ability to work well independently
• Maintain confidentiality

Required

• High School Diploma or GED
• 2 years of experience with obtaining preauthorization’s and/or benefits verifications in a medical office or hospital setting
• Proficient knowledge of CPT/HCPCS and ICD-10 codes
• Knowledge of insurance(s) preauthorization requirements