Pre Authorization

Job Title:Senior Authorization/Pre-Estimate/Patient Access Agent

Department: Revenue Cycle Management

Reports To: Patient Access Supervisor/Manager

Location: Chennai/Hyderabad

Summary:

The Senior Authorization/Pre-Estimate Collection Agent is responsible for securing required authorizations and pre-estimates for healthcare services prior to service delivery and ensuring the collection of patient financial responsibilities related to those pre-estimates. This role requires in-depth knowledge of insurance verification, authorization processes, pre-estimate calculation, and patient communication strategies. The Senior Agent handles complex cases, provides guidance to junior team members, and plays a key role in optimizing upfront collections and minimizing denials.

Essential Duties and Responsibilities:

Authorization Management:

• Verify patient insurance coverage and benefits to determine authorization requirements for planned services.
• Obtain necessary authorizations from insurance payers in a timely manner, using online portals, phone calls, and other methods.
• Document all authorization activities accurately and thoroughly in the billing system.
• Follow up on pending authorization requests and resolve any issues or delays.
• Communicate authorization status to patients, providers, and other relevant parties.
• Appeal authorization denials and follow up on pending appeals.
• Stay current on changes in payer authorization policies and procedures.

Pre-Estimate Collection:

• Calculate accurate patient out-of-pocket expenses (co-pays, deductibles, co-insurance) based on insurance benefits and planned services.
• Communicate pre-estimate information to patients in a clear and understandable manner.
• Collect patient financial responsibility (or establish payment plans) prior to service delivery.
• Document all pre-estimate and collection activities accurately in the billing system.
• Address patient questions and concerns regarding pre-estimates and payment options.
• Reconcile pre-collected amounts with actual charges after service delivery.
• Work with billing and collections teams to resolve any discrepancies.
• Understanding of HIPAA regulations and ensure compliance in all activities.
• Stay current on changes in payer regulations, coding guidelines, and billing requirements

Problem Solving and Analysis:

• Identify trends in authorization denials or pre-estimate collection challenges and propose solutions.
• Work with other departments (e.g., scheduling, registration, billing) to improve pre-service processes.
• Research and resolve complex authorization or pre-estimate inquiries from patients and insurance companies.

Mentorship and Training:

• Serve as a mentor and resource for junior Authorization/Pre-Estimate Collection Agents.
• Assist in training new team members on authorization procedures, pre-estimate calculation, and collection techniques.
• Provide guidance on handling difficult or complex cases.

Reporting and Process Improvement:

• Prepare regular reports on authorization rates, pre-estimate collection rates, and key performance indicators (KPIs).
• Identify opportunities to improve pre-service processes and increase efficiency.
• Participate in team meetings and contribute to process improvement initiatives.

System Proficiency:

• Utilize billing software, insurance verification systems, and other relevant tools to manage authorizations and pre-estimates (e.g., EPIC, Availity, etc.).
• Maintain accurate and up-to-date information in all systems.

Qualifications, Experience & Skills:

• Undergraduate degree or equivalent required; associate or bachelors degree in a related field preferred.
• Minimum of 5-7 years of experience in Patient Access, medical authorization, Prior Auth and/or pre-estimate collection.
• Proven track record of successfully obtaining authorizations and collecting patient financial responsibility upfront.
• Experience working with various insurance payers (e.g., Medicare, Medicaid, Commercial).
• In-depth knowledge of insurance verification and authorization processes.
• Strong understanding of medical billing
• Excellent communication and interpersonal skills, especially in explaining financial information to patients.
• Strong analytical and problem-solving abilities.
• Proficiency in using billing software and Microsoft Office Suite.
• Ability to work independently and as part of a team.
• Excellent organizational and time-management skills.
• Ability to handle a high volume of cases and meet deadlines.

Preferred Qualifications:

• Experience with EPIC preferred but not mandatory.
• Both Hospital and Professional billing experience preferred
• Flexible to work from Office all 5 days in the week

Additional Details: Voice - Pre/Prior Authorization experience will be relevant
Can look for AR/ Calling experience; RCM background is must