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 ConductFlexibility

� 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 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