Job Description

Keystone Advisors is looking for a Prior Authorization Specialist to join our team in Matteson, IL supporting one of our healthcare clients. 

The Prior Authorization Specialist is responsible for obtaining and processing all prior authorization requests , coordinating phone calls, entering and tracking data from insurance providers and health plans regarding authorization, expedited reviews, and appeals. The Prior Authorization Specialist is required to document and track all communication attempts with insurance providers and health plans, follow up on all denials while working to ensure services are validated.  

Typical Duties

• Reviews accounts, and initiate pre-authorizations, and other requirements related to managed care; route to appropriate departments as needed.
• Collects demographic, insurance, and clinical information to ensure that all reimbursement requirements are met.
• Notifies the necessary parties within the required timeframe for routine and urgent requests for services.
• Assists in monitoring utilization services to assure cost effective use of medical resources through processing prior authorizations.
• Communicates with patients and/or referring physicians on non-covered benefits or procedure coverage issues.
• Assists with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
• Provides consistent and comprehensive information (both in writing and verbally) to facilitate approvals.
• Ensures insurance carrier documentation requirements are met and authorization documentation is entered and recorded in the patient’s records.
• Appeals pre-authorization denials and/or set-up peer to peer reviews.
• Maintains an extensive working knowledge and expertise of insurance companies and billing authorization requirements.
• Identifies and reports undesirable trends and re
• imbursement modeling errors or underlying causes of incorrect payment; review allowed variances from third party payers.
• Builds and maintains working relationships with staff, referral sources, insurance companies, and medical providers.

Minimum Qualifications

• High School diploma or GED equivalent with five (5) years of prior authorization experience OR Bachelor’s degree with two (2) years of prior authorization experience
• Three (3) years of experience processing insurance requests to obtain prior authorization
• Experience and familiarity with using insurance portals, i.e., Anthem, Availty, Evicor, Covermymeds, Magellang

Preferred Qualifications

• Knowledge and experience with payer processes to submit appropriate clinical documentation
• Experience using Medical Terminology

Knowledge, Skills, Abilities and Other Characteristics

• Proficiency with Microsoft applications and internet-based programs
• Strong interpersonal skills with the ability to establish strong working relationships
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Strong time management skills to prioritize assignments and meet the designated deadline
• Ability to anticipate, recognize, and meet the needs of the patients and their families
• Ability to work in a team-based environment to accomplish goals and objectives
• Ability to demonstrate respect and sensitivity for cultural diversity in client’s work force and patient population
• Ability to critically think, problem solve and make independent decisions supporting the authorization process, including interactions with payer representatives, physicians, and hospital case managers

Compensation Package:

• Competitive Salary
• Paid Time Off
• Health, Vision & Dental Insurance
• Health Savings Account (HSA)
• Flexible Spending Account (FSA)
• Short & Long Term Disability
• 401 (K) with company match
• Life Insurance

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