Revenue Cycle Specialist II

About the Role:

As a Revenue Cycle Specialist II - Surgery Authorization Specialist, you will play a key role in ensuring timely insurance verification, benefits review, and securing required pre-certifications, authorizations, and referrals prior to surgical services. This role plays a key part in the revenue cycle by ensuring timely approvals, accurate documentation, and clear communication with patients, payers, and clinical teams. This position requires advanced knowledge of medical billing practices, insurance reimbursement guidelines, medical coding, and collection regulations. You will be responsible for resolving complex authorization related issues, leveraging a thorough understanding of company policies and medical payor policies to optimize the revenue cycle processes. 

What You’ll Do:

• Verify insurance eligibility and benefits prior to scheduled surgical services.
• Review, submit, and track surgical authorization and pre-certification requests.
• Communicate with insurance carriers via payer portals and phone to obtain approvals, authorizations, predeterminations and referral as needed.
• Interpret payer medical policies and clinical guidelines to confirm medical necessity.
• Calculate and communicate estimated patient financial responsibility prior to surgery.
• Monitor authorization requests through final determination and follow up on pending cases.
• Collaborate with clinical staff, surgery schedulers, and revenue cycle teams to resolve authorization issues or denials.
• Support escalation cases, including coordination of peer-to-peer reviews when required.
• Accurately document authorization activity and payer communication in the EMR/EPM system.
• Respond to patient inquiries regarding insurance benefits, authorizations, and surgery-related costs.
• Maintain compliance with payer requirements, healthcare regulations, and internal workflows.
• Manage a high volume of work while maintaining accuracy, attention to detail, and excellent customer service.
• Perform other related duties as assigned.