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Healthy Horizons Clinic
Prior Authorization Specialist
Career Insights for Medical Claims Processor / Representative
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Based on Texas 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.
$45,636 / year median in Texas
-1% projected decline
Job Description
Company Overview Healthy Horizons Clinic is dedicated to advancing personalized and precision medicine to prevent and treat diseases effectively. By leveraging cutting-edge genetic testing and innovative technology tools, we strive to provide comprehensive, individualized care that promotes overall wellness and early detection of health issues. Job Overview We are seeking a proactive and detail-oriented Prior Authorization Specialist to join our dynamic team. In this vital role, you will facilitate insurance prior authorization processes, ensuring timely approval for patient treatments and procedures. Your expertise in medical coding, health insurance policies, and electronic health records will be essential in streamlining workflows and enhancing patient care experiences. Duties Review and interpret insurance policies, including managed care guidelines, to determine coverage eligibility for medical services Obtain prior authorization from insurance companies by submitting accurate requests with all necessary documentation Collaborate with healthcare providers to gather clinical information, CPT (Current Procedural Terminology) codes, ICD (International Classification of Diseases) codes (ICD-10), and supporting records Verify insurance benefits and eligibility using electronic health records (EHR) systems and other digital tools Maintain detailed records of authorization requests, approvals, denials, and follow-up actions in compliance with HIPAA regulations Communicate effectively with patients, providers, and insurance representatives to resolve authorization issues promptly Stay current with evolving health insurance policies, clinical confidentiality policies, medical terminology, and coding standards Skills Strong knowledge of HIPAA regulations ensuring patient confidentiality and data security Proficiency in CPT coding, ICD coding (ICD-10), and medical billing processes Experience with electronic health records (EHR/EHR management systems) and Microsoft Office suite In-depth understanding of managed care plans, health insurance policies, and insurance verification procedures Excellent customer service skills with the ability to communicate complex information clearly and professionally Familiarity with medical office operations, medical records management, clinical confidentiality policies, and healthcare documentation standards Ability to multitask efficiently while maintaining attention to detail in a fast-paced environment Join us at Healthy Horizons Clinic where your expertise will directly contribute to delivering personalized healthcare solutions. We value energetic professionals committed to making a meaningful difference through precision medicine!