Claims and Authorization Specialist

Job Description

Job Overview:

The Claims and Authorization Specialist is responsible for managing prior authorization requests, processing corrected claims, and ensuring proper documentation for all claims related activities. This position requires expertise in using billing systems and maintaining compliance with payer guidelines. Experience with CentralReach is highly desired. The specialist will ensure that all claims are accurately processed, authorized when necessary, and documented in a timely and compliant manner.

Key Responsibilities:

Prior Authorization:

•  Submit and track prior authorization requests to insurance companies or other payers.
•  Follow up on pending prior authorization requests and resolve any issues or delays.
•  Communicate with healthcare providers, insurance companies, and patients to ensure all necessary information is submitted for authorization.
•  Ensure prior authorizations are completed accurately and within required timeframes.

Corrected Claims:

• Review denied or rejected claims and identify the cause of issues (e.g., incorrect coding, missing information).
• Submit corrected claims to payers promptly and accurately.
• Track the status of corrected claims and work with payers to resolve any remaining issues.
•  Collaborate with internal teams (e.g., billing, clinical staff) to gather the correct information needed for claim corrections.

 Claims Documentation:

•  Ensure all claims-related documentation is complete, accurate, and compliant with payer and regulatory requirements.
• Maintain organized and accessible records of prior authorizations, claims submissions, and corrected claims.
• Ensure proper documentation of communications with insurance companies, clients, and internal teams.
•  Regularly audit claims and prior authorization records to ensure accuracy and compliance with policies and regulations.
• Adhere to privacy and confidentiality regulations (e.g., HIPAA) in all documentation and communication.

System Experience:

• Proficiency in using billing systems to submit and track claims, including experience with CentralReach (preferred).
•  Ensure claims and prior authorizations are processed through the appropriate systems accurately.
•  Maintain updated knowledge of system functionalities and billing software tools used by the organization.

Qualifications:

• Experience: 2-4 years of experience in claims processing, medical billing, or insurance authorization, with experience in using billing systems.
•  Experience with CentralReach is highly desired.
• High school diploma or equivalent; Associate’s or Bachelor’s degree in healthcare administration, business, or a related field (preferred).
• Certifications Relevant certifications (e.g., Certified Professional Coder (CPC), Certified Billing and Coding Specialist (CBCS)) are a plus.

Skills:

•  Strong knowledge of healthcare claims processes, insurance terminology, coding (CPT, ICD-10), and payer requirements. 
• Excellent attention to detail and organizational skills.
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Benefits:

• Medical, dental and vision insurance
• 401K 
• PTO/Holidays

Qualifications