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.
US Heart and Vascular is in need of a Cardiology Prior Authorizations Specialist to join our team at Willowbrook Cardiovascular Associates in Houston, TX. If you have a passion for obtaining prior authorizations for Veins, Structural Heart and CT Studies, please join our US Heart and Vascular team
Responsibilities:
Ensures timely and accurate insurance authorizations are in place prior to services being rendered. Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt. Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services. Coordinates and supplies information to the review organization (payer) including medical record information and/or letter of medical necessity for determination of benefits. Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review. Communicates with patients, clinical partners, financial counselors, and others as necessary to facilitate the authorization process. Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in all applications. Follows departmental policies and procedures, when necessary, authorization is not obtained before the service date. Answers provider, staff, and patient questions surrounding insurance authorization requirements. Handles escalated authorization requests as needed. Provides team mentorship as needed. Works other departmental tasks as needed.
Requirements:
Familiarity with medical office procedures and billing practices Proficient in clinical documentation review for alignment with insurance authorization requirements Responsible for compliance with all regulatory requirements and/or guidelines. These requirements/guidelines include, but are not limited to: OSHA, HIPAA, Federal Fraud and Abuse laws. High School Diploma or equivalent required Associate's degree in healthcare administration or business administration preferred A minimum of 3-5 years' experience in the same role, or related field in a healthcare setting is required. ECW experience is preferred.
About Houston, TX:
Houston is a diverse city with a booming job market in energy, healthcare, and tech. It has no state income tax, an affordable cost of living, and world-class dining and entertainment. Green spaces, museums, and pro sports teams add to its appeal. Whether for career growth or culture, Houston has it all.
