- Verify patient eligibility, advantages, and insurance coverage through phone calls or electronic verification methods.
- Obtain prior authorizations from healthcare providers for medical services rendered by out-of-network providers.
- Handle denial management by resolving issues related to claims rejection and ensuring timely resolution of discrepancies.
- Utilize CPT codes to identify billing errors and optimize revenue cycle management processes.
- Manage referrals effectively by coordinating with referring physicians, hospitals, and other stakeholders.
Desired Candidate Profile
- 1-5 years of experience in Prior Authorization, Eligibility Verification, Insurance Verification, Denial Management, or Revenue Cycle Management.
- Strong understanding of ICD-10-CM/PCS coding system.
- Excellent communication skills for effective interaction with patients' families and healthcare providers.
- Direct experience with radiology and infusion prior authorizations is required.
- Experience managing prior authorizations from benefit verification through approval,
denial, or appeal.
- Experience working with commercial insurance, Medicare Advantage, and Medicaid managed care plans.
- Strong understanding of authorization requirements for imaging and infusion services.
- Prior experience in healthcare RCM, prior authorization, referral coordination, or insurance operations.
- Experience handling GLP-1 or specialty medication prior authorizations.
- Experience communicating directly with insurance carriers, physician offices, specialist offices, and patients.
- Familiarity with common ophthalmology CPT codes and documentation requirements for eye care authorizations.
- Experience supporting a U.S.-based healthcare practice in a remote or dedicated capacity.
- Experience coordinating peer-to-peer reviews.
- Experience preparing and submitting payer appeals for denied authorizations.
Strong understanding of ophthalmology revenue cycle workflows.