Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.
Contacts insurance company or employer to determine eligibility and benefits for requested services.
Use work queues within the EPIC system for obtaining authorization for referrals, tests, and surgeries within expected timeframes.
Follows up on submitted authorization requests timely.
Ensures accurate coding of the diagnosis, procedure, and facility align with authorization obtained.
Provides authorization verification of services timely to avoid unnecessary delays in treatment and reduce excessive nonclinical administrative time required of providers.
Utilize payor resources and any other applicable reference material such as payor and medical policies to verify accurate prior authorization.
Review and interpret medical record documentation to answer clinical questions during the authorization process.
Scheduling and following up on peer to peers and denials. Submitting and following up with prior authorization appeals for denied surgeries.
Assists Patient Financial Services with denial management issues and will obtain retro-authorizations as needed.
Notifies scheduling and physicians of any cases not authorized within department policy.
Works collaboratively and politely with internal and external contacts specifically Physicians, Financial Clearance/Counselor, Schedulers, and Nurses.

High school graduate or equivalent with 2 years working experience in a medical environment, (such as a hospital, doctor’s office, or ambulatory clinic.) OR 2. Associate’s degree and 1 year of experience in a medical environment required.
3 years’ experience of knowledge and interpretation of medical terminology, ICD-10, and CPT codes.
Understanding of authorization processes, insurance guidelines, and third-party payors.
Proficiency in Microsoft Office applications.
Excellent communication and interpersonal skills.
Ability to prioritize to meet deadlines and multitask a large work volume with a high level of efficiency and attention to detail.
Basic computer skills.

Insurance Authorization Specialist II

Key skills