Eligibility, Benefits & Authorization Representative needed for Large Healthcare Company.


This position receives/responds to incoming/outgoing calls and identifies potential payer sources. Requests authorizations with the payors. Provides verification online and by phone with payers. Participates in utilization management performance improvement activities (specific measurement for contracts). Works under moderate supervision with clinical oversight and input.

PRIMARY RESPONSIBILITIES:

Abides by and demonstrates the company Mission Vision Values through both behavior and job performance on a day-to-day basis.

Contacts health plans or payors to gather policy benefits/limitations and completes eligibility and benefits verification to ensure services provided will be covered by the carrier. (e.g., deductible amounts, co-payments, effective date, pre-existing clauses, levels of care, authorization, visit limitations, documentation required to process claims, etc.). Documents all communications and decisions into a computer database or on a manual form.

Identifies potential payer sources, verifies benefits with payer sources (as required by department organizational structure), and obtains initial authorization from the authorizing entity. Establishes primary payers and documents conversations and decisions with payer sources on appropriate forms.

Gain knowledge on applicable payer guidelines and provide documentation of Eligibility, Benefits and Authorization.

Works closely with healthplans/payers and maintains strong business relationships.

Participates in and contributes to utilization management and performance improvement activities.

Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.

Participates in implementing / maintaining operational processes to ensure compliance to Company policies, legal requirements and regulatory mandates.

REQUIRED EDUCATION / EXPERIENCE

High School Diploma or the equivalent plus experience with insurance or claims experience required. Medical terminology, insurance verification or healthcare experience required. Knowledge of basic spreadsheet / word processing / data entry skills both speed and accuracy required. Must be committed to quality and high standards. Be able to provide issue resolution and escalation when appropriate. Must be able to handle large call volume.