Prior Authorization Representative Retina

Description

The Prior Authorization Representative for Retina is responsible for managing all prior authorizations and copay assistance applications related to intravitreal injections and retina-specific medications. This includes verifying eligibility, coordinating with payers, enrolling patients in financial assistance programs, and ensuring timely approvals to avoid treatment delays.

Core Behavioral Values 

• CLEAR ID: Collaborate, Learn, Empathy, Accountable, Respect, Integrity, Dedication
• These behaviors are based on Eyesight’s culture and values critical to support the organization’s mission of providing uncompromising care to patients. 

Requirements

Essential Functions

• Review retina clinic schedules to identify patients requiring prior authorizations
• Verify insurance eligibility and benefit details for injectable medications and procedures
• Obtain all necessary prior authorizations for retina injections, ensuring appropriate ICD-10, CPT, and HCPCS codes are submitted
• Submit supporting clinical documentation, including notes, diagnostics, and test results, to facilitate approvals
• Track, follow up on, and document all pending and retro-authorization requests
• Maintain accurate logs of prior authorization statuses, expiration dates, and coverage limitations
• Coordinate and apply for manufacturer-sponsored copay or patient assistance programs for eligible patients
• Confirm that all prior authorization and financial assistance outcomes are documented in the PM/EMR system
• Upload and maintain updated insurance and authorization documentation
• Collaborate with retina technicians and schedulers to ensure patients are cleared for treatment
• Communicate with payors to resolve issues related to delays or denials.
• Appeal denied authorizations as appropriate
• Maintain current knowledge of payer-specific rules for specialty drugs and retina procedures
• Assist with insurance verification and accurate plan entry when discrepancies are found
• Support patients during checkout, especially for financial discussions related to treatment plans
• Answer clinic and patient questions related to billing, coverage, and assistance programs

Qualifications

• Minimum 5 years’ experience in medical billing; 2+ years in a supervisory or lead role required
• Strong understanding of ophthalmology billing, coding (CPT/ICD-10), and payer rules (Medicare, Medicaid, commercial)
• Experience with revenue cycle platforms and EHRs (ModMed preferred); ClickUp and PODIS experience a plus
• Ability to lead, motivate, and hold a team accountable while fostering a collaborative, solutions-oriented environment
• Strong analytical, problem-solving, and organizational skills
• Excellent written and verbal communication skills

Preferred

• Billing/Coding certifications (e.g., COA, OSC, CPC) strongly preferred
• Experience navigating payer portals and submitting appeals, PAs, and audits
• Working knowledge of retina-specific medications, co-management billing, and financial assistance workflows

Work Conditions

• Professional healthcare setting, including clinics, administrative areas, and patient-facing environments
• Noise level ranges from quiet to moderate, depending on location and activity
• Potential exposure to infectious diseases, bodily fluids, or cleaning agents in accordance with standard protocols

Physical Requirements

• Ability to sit, stand, and walk for extended periods
• Frequent use of hands and fingers to operate medical or office equipment
• Clear verbal and written communication; ability to hear and understand speech in person and by phone
• Close vision required for reading small print and viewing computer screens
• Occasional lifting or moving of objects up to 25 pounds
• May involve reaching, bending, stooping, kneeling, or other physical movement
• Ability to manage multiple priorities and maintain professional interactions in a dynamic setting