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Next Steps Pediatric Therapy
Prior Authorization Specialist
Career Insights for Medical Claims Processor / Representative
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Based on Mississippi 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 Mississippi
-4% projected decline
Job Description
Overview We are seeking a highly motivated and detail-oriented Prior Authorization Specialist/Biller to join our dynamic healthcare team. In this vital role, you will serve as the primary point of contact for managing insurance prior authorization requests, ensuring timely approval for patient treatments and procedures. Your expertise will help streamline the authorization process, improve patient care coordination, and maintain compliance with healthcare regulations. This position offers an exciting opportunity to contribute to a fast-paced environment where your skills in medical billing, coding, and insurance verification will make a meaningful impact. Responsibilities Review and interpret insurance policies, including health insurance policy knowledge, to determine coverage eligibility for various medical services and procedures. Obtain prior authorization from managed care organizations by accurately completing and submitting authorization requests via electronic health records (EHR) systems or other platforms. Utilize medical terminology, CPT coding, ICD-9, ICD-10, and ICD coding to provide precise clinical information supporting authorization requests. Verify patient insurance coverage through insurance verification processes and update electronic health records (EHR) accordingly. Communicate effectively with healthcare providers, insurance companies, patients, and other stakeholders to facilitate smooth authorization workflows. Maintain strict adherence to HIPAA regulations and clinical confidentiality policies when handling sensitive medical records and personal health information. Track and document all authorization requests, follow-up actions, and outcomes within the medical office's electronic systems to ensure compliance and accountability. Experience Prior experience in a medical office setting or healthcare environment is preferred, demonstrating familiarity with office procedures and medical records management. Strong knowledge of health insurance policies, managed care processes, and insurance prior authorization protocols is essential. Proficiency in Microsoft Office applications (Word, Excel) for documentation and reporting purposes. Experience with Electronic Medical Records (EMR) or Electronic Health Records (EHR) management systems is highly desirable. Knowledge of medical billing, medical coding (CPT, ICD), and insurance verification processes will enhance your effectiveness in this role. Excellent customer service skills combined with the ability to communicate complex information clearly and professionally. A solid understanding of clinical confidentiality policies and HIPAA compliance ensures the protection of patient data at all times. Join us as a Prior Authorization Specialist/Biller and be part of a dedicated team committed to delivering exceptional healthcare support through efficiency, accuracy, and compassionate service!