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PG
Pioneer GI Clinic
Prior Authorization Specialist
Career Insights for Medical Claims Processor / Representative
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Based on Alaska data
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What they do
A Medical Claims Processor or Representative reviews and processes medical insurance claims and determines whether an insurance policy will cover a medical procedure. Gathers information from policy holders and organizes insurance files; may process checks with payments to policy holders when a medical claim is approved.
$45,209 / year median in Alaska
-3% projected decline
Job Description
Job Summary We are seeking a proactive and detail-oriented Prior Authorization Specialist to join our healthcare team. In this vital role, you will be responsible for managing insurance prior authorization requests to ensure timely approval for patient treatments and procedures. Your expertise will help streamline the approval process, facilitate effective communication with insurance providers, and support our commitment to delivering exceptional patient care. The ideal candidate will possess a strong understanding of medical terminology, insurance policies, and electronic health records management, all while maintaining strict adherence to confidentiality policies. Responsibilities Review and interpret insurance policies, including health insurance and managed care plans, to determine coverage eligibility for specific procedures or treatments. Prepare and submit prior authorization requests accurately using electronic health records (EHR) systems and other digital platforms. Communicate effectively with insurance companies to follow up on pending authorizations, resolve discrepancies, and expedite approvals. Maintain comprehensive documentation of all authorization requests, approvals, denials, and related correspondence in medical records. Collaborate with healthcare providers, billing teams, and patients to gather necessary clinical information and ensure compliance with medical coding standards such as CPT (Current Procedural Terminology), ICD-10, and ICD coding. Stay updated on changes in health insurance policies, clinical confidentiality policies (including HIPAA), and medical billing regulations to ensure accurate processing. Provide excellent customer service by addressing inquiries from patients and providers regarding authorization status or documentation requirements. Experience Prior experience working in a medical office environment or healthcare setting is highly preferred. Demonstrated knowledge of health insurance policies, managed care processes, and insurance verification procedures. Familiarity with medical terminology, medical records management, and electronic health record (EHR) systems such as EMR/EHR platforms. Experience with insurance prior authorization processes. Strong understanding of clinical confidentiality policies like HIPAA to safeguard patient information. Join us to play a crucial role in facilitating seamless healthcare delivery through efficient prior authorization management!