Lead Authorization Specialist

Job Description

Job Description

Lead Authorization Specialist - Centennial, Co

Compensation : $20 - $26 Hourly

Overview : Nexus HR is looking for an experienced Lead Authorization Specialist for a reputable clinic in Centennial, Co.

About the Job

The Lead Authorization Specialist oversees the insurance authorization process for our Infusion, Biologics, ENT surgeries, and Botox services.

The role involves leading a team of specialists, ensuring timely authorizations, working closely with insurance providers, and maintaining adherence to all payer and regulatory guidelines.

This position is based in our Centennial, Co location and reports directly to the Revenue Cycle Management (RCM) Manager.

Duties and Responsibilities :

Team Leadership

Supervise and guide the authorization team, ensuring all authorization processes are efficiently handled.

Report directly to the RCM Manager regarding the performance and functionality of the team.

Train and mentor team members on payer requirements, pathways, and insurance processes.

Authorization Management

Review and process insurance authorizations for Infusion and Biologic services, ENT surgeries, and Botox.

Audit the medical necessity for each treatment, including verifying ICD-10 codes and pathway adherence.

Obtain insurance authorizations and pre-certifications, acting as a liaison between the patient, insurance provider, and clinical staff.

Patient Advocacy and Communication

Serve as a patient advocate, providing answers to reimbursement questions and addressing insurance delays.

Communicate authorization status to medical staff within 24 hours and provide updates on stat requests within the same day.

Inform physicians and management of any documentation or payer issues related to non-covered services.

Claims Follow-up and Denial Management

Handle denial follow-ups, process insurance correspondence, and maintain accurate reimbursement records.

Track payer trends and report any emerging issues to management.

Regulatory Compliance

Maintain knowledge of federal, state, and payer-specific regulations regarding Infusion, Biologics, ENT surgeries, and Botox.

Ensure compliance with patient confidentiality laws (e.g., HIPAA).

Program Support and Benefit Explanation

Work with financial assistance programs to ensure patients have the necessary coverage.

Discuss insurance benefits with patients and help them understand their financial responsibilities.

Qualifications :

Education : High school diploma or equivalent (required).

Experience :

Minimum of 5 years of medical insurance verification and authorization experience.

At least 2 years of experience in a management or team lead role.

Billing and coding experience preferred.

Skills :

Strong leadership and communication abilities.

In-depth knowledge of insurance verification and medical coding (ICD-10, CPT).

Ability to multitask in a fast-paced environment and maintain accuracy.

Benefits :

401(k) and 401(k) matching

Health, dental, and vision insurance

Life and disability insurance (short-term and long-term)

Flexible spending accounts (FSA)

Health Savings Accounts (HSA)

Employee Assistance Program (EAP)

Paid time off (PTO) and holiday pay

Wellness programs