Prior Authorization/Credentialing Coordinator

Job Title: Prior Authorization/Credentialing Specialist

Location: [Location]
Reports To: [Position Title]
Position Type: Full-time, [Contract/Permanent]

Position Overview:

The Prior Authorization/Credentialing Specialist is responsible for managing the processes involved in securing prior authorizations for services and ensuring the proper credentialing of healthcare providers within our network. This role ensures compliance with regulatory and payer requirements, optimizing the workflow for service approval and the smooth enrollment of providers. The ideal candidate will have a strong understanding of healthcare insurance, medical coding, and credentialing processes.

Key Responsibilities:

Prior Authorization:
? Initiate, track, and manage the submission of prior authorization requests for medical services, procedures, and treatments as required by insurance carriers.
? Review patient files, insurance requirements, and medical necessity guidelines to determine the need for prior authorizations.
? Communicate directly with insurance companies, healthcare providers, and patients to gather necessary information and resolve authorization issues.
? Follow up on pending prior authorization requests to ensure timely approvals or denials.
? Maintain accurate records of all prior authorization interactions, including request dates, outcomes, and any necessary follow-up actions.

Credentialing:
? Facilitate the credentialing process for new and existing healthcare providers, ensuring they are fully enrolled with insurance companies and other third-party payers.
? Submit applications for provider credentialing to insurance carriers and assist in the re-credentialing process as needed.
? Track and maintain credentialing documentation, including licensure, certifications, and malpractice insurance.
? Ensure that all credentialing processes comply with state and federal regulations as well as company policies.
? Assist in resolving any credentialing issues or discrepancies that may arise.

Communication & Collaboration:
? Act as a liaison between insurance companies, healthcare providers, and the internal team to facilitate the smooth processing of authorizations and credentialing.
? Educate providers and clinical staff about authorization requirements and credentialing policies to ensure compliance with insurance carriers.
? Coordinate with billing and coding teams to ensure that authorized services are accurately documented and coded.

Reporting & Documentation:
? Maintain up-to-date records of all authorization and credentialing statuses in the appropriate software system or database.
? Prepare reports and updates for management regarding the status of prior authorization requests, credentialing applications, and overall departmental performance.
? Document any denials or delays in the authorization or credentialing process and work with the appropriate parties to resolve them.

Compliance:
? Stay current on insurance payer guidelines, changes in policy, and regulatory requirements related to prior authorization and provider credentialing.
? Ensure compliance with HIPAA regulations and other privacy standards when handling patient and provider information.

Qualifications: ? Education: ? High School Diploma or equivalent required; Associate?s or Bachelor?s degree preferred in Health Administration, Healthcare Management, or related field. ? Experience: ? Minimum of 2-3 years of experience in prior authorization, credentialing, medical billing, or healthcare administration. ? Familiarity with insurance plans, payer networks, and medical necessity guidelines. ? Knowledge of healthcare regulations, including HIPAA and insurance compliance. ? Skills: ? Strong organizational skills with the ability to manage multiple priorities and deadlines. ? Excellent written and verbal communication skills to interact with insurance carriers, healthcare providers, and internal staff. ? Detail-oriented with a focus on accuracy and efficiency in all tasks. ? Proficiency in Microsoft Office Suite (Excel, Word, Outlook). ? Experience with healthcare credentialing software and prior authorization systems (e.g., CAQH, TrakCare, Availity) preferred. ? Ability to analyze and interpret medical documentation and insurance policy requirements.

Preferred Qualifications: ? Experience working with specialized insurance payers (e.g., Medicaid, Medicare, commercial insurance). ? Familiarity with medical terminology, coding (CPT, ICD-10), and billing processes.

Job Type: Full-time

Pay: From $55,000.00 per year

Benefits:
? 401(k)
? Dental insurance
? Health insurance
? Life insurance
? Paid time off
? Vision insurance

Work Location: Remote

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