Senior Reimbursement Specialist - Prior Authorization
- Spring, TX
- Permanent
- Full-time
- Manage Prior Authorization Lifecycle: Independently handle the full prior authorization process, ensuring timely approvals while navigating complex payer policies.
- Optimize Billing Operations: Collaborate with the billing tool provider and internal teams to enhance billing efficiency in alignment with company goals.
- Resolve Reimbursement Issues: Spearhead efforts to address and troubleshoot complex denials, escalations, and reimbursement challenges.
- Facilitate Communication: Work closely with ordering physician offices and internal teams to ensure seamless communication and efficient claim resolution.
- Maintain Accurate Documentation: Manage payer communications, correspondence, and insurance claims research while ensuring proper documentation.
- Develop Training & Quality Control: Contribute to the design and implementation of training and quality assurance programs to enhance team performance.
- Collaborate with Offshore Teams: Work with Reimbursement management and offshore teams handling prior authorization cases to streamline operations
- Accurately enter and maintain data in computer systems, ensuring precise account notation.
- Verify and communicate insurance eligibility, billing and prior authorization details, collections, and payment responsibilities to appropriate parties.
- Draft and submit written appeals with a proven track record of success.
- Interpret Prior Authorization Denials, Explanation of Benefits (EOBs) and correspondence accurately for follow-up actions or appeals.
- Adhere to HIPAA guidelines when providing medical records to primary care providers, insurance carriers, referred providers, and patients.
- Work effectively both independently and as part of a team to achieve set goals.
- Perform other related duties as assigned.
- Minimum 5 + years recent experience in both professional and facility coding, billing, and prior authorization with high volume and/or multiple accounts
- Experience with contacting and follow up with insurance carriers on denials, file reconsideration requests, formal appeals and negotiations
- Experience working with a broad range of payers and have appealed to state level agencies or external level review with IRO/IRBs are a plus.
- Must be proficient using a computer, data entry, and have above average typing skills
- Intermediate to advanced MS Office including Excel
- Familiarity with laboratory billing, Xifin, EDI enrollment, merchant solutions, payer portals and national as well as regional payers throughout the country are a plus
- High school diploma or equivalent, bachelor’s degree or equivalent work experience preferred