Payor Specialist - Healthcare Prior Authorizations

Payor Specialist - Healthcare Prior Authorizations

The Payor Specialist is responsible for verifying insurance coverage, submitting authorization requests and maintaining follow-up communication with insurance companies. More specifically, this role verifies patient insurance benefits for specific procedure coverage, facilitates product related authorization/approval, and requests network or payment related exceptions.

This position will support multiple products simultaneously, requiring strong prioritization and coordination skills, and will include working through complex coverage scenarios. Experience navigating nuanced or layered coverage requirements would be valuable.

Core Duties/Responsibilities

• Works directly in alignment with Case Management Team to coordinate efforts and prioritize daily activities to meet deadlines.
• Obtains timely payor determinations regarding certifications of needs and accurately records and conveys the determination to the Payor Specialist Manager/Case Management Team
• Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate Payor Specialist Manager/Case Management Team as applicable.
• Clearly documents and communicates authorization outcomes and applicable follow up steps for approval to the Payor Specialist Manager/Case Management Team
• Communicates out-of-network obstacles and takes proactive steps to elevate network status and optimize in-network patient benefits to the Payor Specialist Manager/Case Management Team.
• Provides feedback to Payor Specialist Manager/Case Management Team as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
• Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills
• Proactively follows up on pending payor correspondence to encourage priority review and expedited turnaround times.
• Interprets payor documentation to ensure accuracies and translates appropriately to the Case Management Team, customer, and patient.
• Follows procedures and instructions to escalate or expedite authorization review timelines to meet patient and provider treatment scheduling expectations.
• Work collaboratively and cross-functionally between management and programs
• Additional duties as assigned

Skills / Requirements

• Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities.
• Remains calm and objective in emotional or stressful situations.
• Learns quickly and applies innovative methods, tools, and technology to the role.
• High level of self-accountability for compliance with policies, procedures, and work requirements.
• Seeks advice when unsure about choosing a course of action.
• Makes solid routine decisions with coaching from others.
• Learns about the key drivers of the organization’s business and uses those learns in the day-to-day work.
• Maintains tenacity and work focus despite obstacles