Insurance Verification and Prior Auth Specialist

Primary Job Functions[1]:

• Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.


• Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for patients. Follows up with internal departments, physician offices, patients and third-party payers to complete the pre-certification process.


• Identifies out of pocket amounts (i.e., copay, deductible, co-insurance), determining the correct coordination of benefits, identifying if a replacement or supplemental plan exists, identifying termed coverage, and identifying if the patient's plan is considered out of network coverage.


• Collaborates with internal departments to provide account status updates, including expected out of pocket amounts, coordinate the resolution of issues, and appeal denied authorizations.


• Ensures services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance. Notifies ordering providers if authorization/certification is denied.


• May need to coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.


• Maintains files for referral and insurance information, and enters referrals into the system.


• Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.


• Runs system-generated reports to verify insurance verification/authorization is being done timely prior to the patient's date of service; verifies the insurance benefits and eligibility either by phone or online for every patient that is scheduled


• Responds to patient calls about how out of network insurance is handled and provide patient with letter explaining this if necessary.


• May need to respond to patient inquiries about their insurance benefits.


• Assists physician’s office staff with any insurance benefit questions and educate them on any changes to the insurance companies’ verification/pre-certification process for the facility.


• Ensures insurance information is verified and entered into the billing system.


• Works with Billing Department to assure all insurance information is entered so claims are not denied. May help research any claim issues.


• Other duties as assigned.

Secondary Job Functions:

• Attend meetings and training sessions


• Maintain confidentiality of patient and financial information by utilizing HIPAA guidelines and regulations


• Adheres to all Federal, State, and Local laws and regulations as well as policies set forth by Ohio Gastroenterology Group Inc and its related parties

Knowledge, Skills and Abilities

• Knowledge of third-party payers and prior-authorization requirements


• Understanding of basic medical terminology and procedures


• Proficient use of office equipment, such as copier and fax machine, phones, etc.


• Intermediate computer skills including use of Microsoft Office (Excel and Word), electronic mail, payer websites, physician practice management, and electronic medical records systems.


• High attention to detail and the ability to multi-task.


• Strong time management skills


• Ability to work independently with minimal supervision and to manage multiple priorities.


• Strong written and verbal communication skills


• Ability to effectively communicate with a variety of people under stressful circumstances.

• Neat appearance, professional demeanor and pleasant voice


• Fluent in English

Credentials and Experience

• Must have high school diploma or equivalent


• One (1) year of experience and relevant knowledge of revenue cycle functions, insurance eligibility, or prior authorization in a healthcare setting preferred


• • Experience with eClinicalWorks a plus

Physical Demands

• Must be able to bend over (frequent), climb stairs (frequent), sit (frequent), stand (frequent), stoop (frequent), walk (frequent) and type on keyboard (frequent).

Work Environment

• Minimal medical office exposure that may require contact with adult patients


• Office workstation environment with numerous employees

[1] Critical features of this job are described under this heading.  They may be subject to change at any time due to reasonable accommodation or other reasons,