Reimbursement Specialist – Prior Authorization

Reimbursement Specialist – Prior Authorization

Requirements

• 0-2 years of experience in the healthcare industry.
• Strong understanding of health plan regulations, billing processes, and third-party payer requirements.
• Excellent organizational skills, with high attention to detail and accuracy.
• Self-motivated with the ability to work independently in a fast-paced environment.
• Tech-savvy with proficiency in Excel (sorting, filtering, basic calculations).

Responsibilities

• Act as a primary contact for insurance companies to obtain necessary preauthorizations for patient services.
• Collaborate with billing systems, finance, and client services teams to facilitate timely payment processing.
• Maintain and update a comprehensive database of payer authorization requirements.
• Manage all documentation related to payer communication, correspondence, and insurance claims research.
• Track, report, and resolve complex claims, ensuring prompt follow-up and resolution.
• Troubleshoot Explanation of Benefits (EOBs), identify claim issues, and escalate as needed.
• Appeal non-covered or incorrectly adjudicated claims through external review processes.
• Drive positive coverage decisions via appeals and external review organizations.
• Ensure compliance with Medicare, Medicaid, and other third-party payer requirements and online eligibility/preauthorization systems.
• Support continuous improvement of billing and authorization processes aligning with company values.

Preferred Qualifications

• Experience with insurance and payer relations.
• Experience working with a diverse range of payers, insurance portals, and prior authorization processes.
• Proven ability to coordinate with insurance providers, physicians, and patients.
• Knowledge of laboratory billing, Xifin, EDI enrollment, and merchant solutions is a plus.
• Experience with appeals at state and external review organizations (IROs/IRBs) is a plus.