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.

DUTIES AND ESSENTIAL JOB FUNCTIONS

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.

Other functions and Responsibilities

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.

COMPETENCIES

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

QUALIFICATIONS

Required

High School Diploma or GED

2 years of experience with obtaining preauthorizations 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