Full-Time Reimbursement Specialist II

Reimbursement Specialist II - Prior Authorization - Screening

About the Role: A seasoned expert in the revenue cycle team, driving impact through deep knowledge of insurance processes, payer policy, and prior authorization strategy. Ensure patients receive timely access to care and maximize reimbursement outcomes. Independently manage the full prior authorization lifecycle. Navigate complex payer policies, secure timely approvals, and resolve escalated reimbursement issues. Streamline processes, troubleshoot complex denials, and collaborate with team members and physician offices for seamless communication. Collaborate with Finance, Client Services, Account Managers, and billing technology partners. Champion best practices and contribute to a compliant billing operation. Help build and maintain comprehensive payer requirements documentation and support process improvement initiatives.

Key Responsibilities:

1. Manage the full prior authorization lifecycle, including navigating complex payer policies and securing timely approvals.
2. Actively review, submit, track and resolve Prior Authorization inquiries until final approval is obtained.
3. Resolve escalated rejected authorizations issues and streamline processes for efficiency.
4. Research system notes to obtain missing or corrected insurance or demographic information.
5. Prepare and submit necessary medical records, documentation, and justification to insurance companies.
6. Ensure all required documentation is complete and accurate to avoid delays in authorization.
7. Manage faxes, emails, phone calls, and respond to voicemails and emails.
8. Maintain comprehensive documentation of payer requirements and support process improvement initiatives.
9. Follow appropriate HIPAA guidelines.
10. Communicate effectively with cross-functional teams and ordering physician offices to identify and address inefficiencies impacting ASP and claims adjudication processes.
11. Work closely with staff to investigate and resolve delays, rejections, or discrepancies related to claims submissions.

Minimum Qualifications:

• 3+ years of healthcare reimbursement experience, with a strong focus on prior authorization, insurance coordination, payer relations, and appeals.
• Expert-level knowledge of Medicare, Medicaid, IPA, and commercial payer authorization policies and appeals processes.
• Proven success in managing complex claims, including overturning denials through advanced appeal strategies and external reviews.
• Proficiency with revenue cycle tools and systems (Xifin/Telcor, payer portals, Salesforce).
• Proven track record of cross-functional collaboration.
• Exceptional attention to detail, self-motivated, organizational abilities.
• Experience with laboratory billing workflows and national/regional payer requirements (preferred).
• Proficiency with computer hardware, PC software (Microsoft Office Suite, Adobe Acrobat PDF, Excel).
• Excellent communication and interpersonal skills.
• Ability to work independently and handle confidential information.

Salary: $22.39 - $30.79/hour (full-time)

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