Insurance Authorization Specialist

Summary/Objective 
Under limited supervision, the Insurance Authorization Specialist reviews and manages benefits, eligibility, and prior authorizations for hospitals and physicians, acting as a vital intermediary between the medical institution, patients, and insurance agencies. This role performs pre-registrations for scheduled accounts across multiple affiliates, coordinates financial estimations, and establishes patient payment arrangements. The Specialist acts as the primary documentation source for access and billing staff to optimize reimbursement and minimize financial risk.

Essential Job Functions 

• Maintain work queues and reports assigned by the supervisor and client.

• Complete eligibility checks and verify benefits for inpatient and outpatient, scheduled and nonscheduled visits via phone or electronic payer systems.

• Contact patients, families, and physicians to collect, analyze, and record accurate demographic, clinical, and insurance/financial data.

• Update information in the system to ensure an appropriate information source for a clean verification and billing process.

• Refer patients requiring structured payment plans to cash posting specialists.

• Adhere to all corporate policies, procedures, and regulatory standards, including EMTALA, HIPAA, and HIPAA HITECH.

• The duties listed above are representative of the role, and an individual may be responsible for performing all, or a specific subset, of these functions. Additionally, individual may be required to perform other related tasks and responsibilities as applicable or assigned to meet operational and client needs.

Key Success Indicators/Attributes

• Must be adept at multi-tasking and prioritizing a variety of tasks, often changing assignments on short notice in a fast-paced environment.

• Strong analytical, critical thinking, and problem-solving skills to successfully manage individual KRAs and meet production metrics.

• Excellent verbal, listening, and written communication skills to build trust, maintain credibility, and remain composed during stressful situations.

• Perform data entry with accuracy while safeguarding corporate and client assets, proactively reporting any security compromises.

• Skill in operating a computer and learning multiple software or hardware systems concurrently within an average workday.

Supervisory Responsibility

No

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• High school diploma, or equivalent.

• Minimum 1-2 years of experience in medical billing, coding, hospital patient access, patient accounts, or a medical clinic environment.

• Comprehensive understanding of hospital/physician billing and terminology (e.g., CPT, ICD-10, ICD-9, co-pays, deductibles, or co-insurance).

• Previous customer service experience interacting professionally with a diverse environment.

Preferred Education and Experience

• Prior experience working directly with third-party payers, collections, and navigating insurance verification or eligibility systems.

• Familiarity with coding conventions and rules established by AHIMA, the American Medical Association (AMA), the American Hospital Association (AHA), and the Center for Medicare and Medicaid Services (CMS).

Additional Eligibility Qualifications 

N/A

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities, and activities may change at any time with or without notice.  Employee may perform other duties as assigned.