01Overview
Role Objective We are seeking a detail-oriented Prior Authorization Specialist with a focus on Urology to join our team. You will be responsible for ensuring that all urological procedures, diagnostic tests, and medications are pre-approved by insurance carriers, minimizing denials and ensuring seamless patient care.
Key Responsibilities Authorization Management: Submit and track prior authorization requests for urology-specific services, including cystoscopies, vasectomies, UroLift, and oncological treatments.
Clinical Review: Review patient charts and medical necessity documentation to ensure they meet payer-specific criteria.
Payer Communication: Proactively follow up with insurance companies (U.S.-based payers) via web portals and phone to expedite approvals.
Denial Prevention: Identify potential \"red flags\" in documentation that could lead to denials and collaborate with the clinical team to rectify them.
Data Integrity: Update the Practice Management (PM) system with approval numbers, validity dates, and authorized units.
Appeal Support: Assist in the administrative appeal process for denied authorizations by gathering necessary clinical notes.
Required Qualifications & Skills Experience: 15 years of experience in US Healthcare RCM, specifically in Prior Authorization.
Domain Knowledge: Solid understanding of Urology ICD-10 and CPT codes (e.g., 52000 series, 55866).
Communication: Excellent verbal and written English communication skills, as you will be interacting with US insurance providers.
Technical Savvy: Proficiency in EMR/EHR systems (e.g., AthenaOne, eClinicalWorks, or NextGen).
Analytical Thinking: Ability to interpret complex medical policies and \"Medical Necessity\" guidelines. .
