Eligibility, Benefits, Prior Authorization Specialist

Responsibilities

• Verify active patient insurance coverage, deductibles, co-pays, co-insurance, and coordination of benefits (COB) across commercial plans
• Conduct in-depth research on payer-specific policies regarding virtual care, remote developmental pediatrics, and psychological evaluations (CPT 90791, 96130, etc.)
• Navigate payor websites, newsletters, and provider manuals to track and document shifting policy guidelines and billing modifiers across 40+ states
• Review incoming clinical diagnostic referrals and orders to ensure demographic, insurance, CPT, and ICD-10 data are flawless
• Initiate, track, and validate prior authorizations through clearinghouses (e.g., Availity, Waystar), insurance portals, and phone escalations
• Ensure all authorizations are secured, confirmed accurate, and fully documented in the EMR before the close of business each day for upcoming clinics
• Act as the go-to resource for clinical teams when a payer's prior-authorization process is vague, contradictory, or unmapped
• Validate conflicting information from multiple insurance sources to determine the most credible, risk-free path for claim submission
• Build, update, and maintain internal state-by-state reference guides on commercial insurance and state-by-state regulatory requirements
• Prepare clear, professional patient insurance benefit letters outlining estimated out-of-pocket costs and referral requirements
• Collaborate closely with clinic coordinators and clinical staff to resolve last-minute scheduling exceptions or authorization gaps
• Help de-escalate patient or provider concerns regarding coverage limits with professional, empathetic communication

Requirements

• 2+ years of healthcare clinic or startup experience specializing in insurance verification and prior authorizations
• Strong research capabilities: deep comfort navigating payor portals, digging through policy manuals, and calling payor representatives to clarify ambiguous rules
• Hands‑on experience working with multiple major commercial payers (e.g., BCBS, Optum, Aetna)
• Working knowledge of medical terminology, CPT, ICD‑10, and telehealth billing modifiers
• Excellent written and verbal English communication skills: ability to translate technical insurance terms into simple, clear explanations
• High‑speed internet, backup power setup, and the ability to work full‑time during EST business hours

Core Competencies

Demonstrates expertise in insurance verification and prior authorizations, with a strong ability to navigate payer policies and communicate effectively with clinical teams and patients. Proficient in medical terminology, CPT, ICD‑10, and telehealth billing practices.