BPN Insurance Verification and Authorization Specialist

Bryan Health - Lincoln, NE

Full-time

Lincoln, NE

Hospitals

About the position

The position involves reviewing procedures, referrals, and prescription medications against insurance policies to ensure compliance with payer guidelines before services are rendered, aiming for maximum reimbursement. The role requires effective communication with various stakeholders regarding service authorizations and managing retro-authorizations and peer-to-peer reviews between payers and providers.

Responsibilities

• Reviews all procedures, referrals, and prescription medications with applicable insurance policies to ensure compliance with payer guidelines.
• Communicates with hospital departments, physician offices, and patients regarding pre-service authorizations.
• Adheres to federal regulations including Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA, and HIPAA.
• Maintains productivity and quality standards as defined by organizational goals.
• Submits patients' supporting medical records and necessary information to payer authorization representatives for prior authorizations.
• Submits prior-authorization requests for prescription medications using various methods.
• Documents all actions taken regarding the prior authorization process accurately in the applicable systems.
• Ensures completion of pre-certification and/or authorization and referral requirements by contacting relevant parties.
• Explains non-coverage notices and offers to reschedule elective tests and procedures when pre-authorization is not obtained.
• Coordinates obtaining waivers of liability when third-party payers deny coverage.
• Prepares and provides patients with cost estimates for expected services.
• Maintains accurate payer website information and logins for authorization requirements.
• Communicates with Patient Financial Services regarding denials and appeals from payers.
• Maintains professional growth through seminars and workshops.
• Participates in meetings, committees, and department projects as assigned.

Requirements

• High School diploma and one (1) year relevant work experience in a medical clinic, health care, insurance industry, pharmacy, or medical billing office required.
• Knowledge of third-party payer requirements.
• Knowledge of ICD 10/CPT coding.
• Knowledge of basic human anatomy, medical and pharmaceutical terminology.
• Ability to communicate effectively both verbally and in writing.
• Ability to prioritize work demands and work with minimal supervision.

Nice-to-haves

• Certified Medical Assistant or Medication Aide certification preferred.
• Coding certificate or other clinical background preferred.