Eyesightnh
Prior Authorization Representative – Retina
Eyesightnh, Somersworth, New Hampshire, us, 03878
Description
The Prior Authorization Representative for Retina is responsible for managing all prior authorizations and copay assistance applications related to intravitreal injections and retina-specific medications. This includes verifying eligibility, coordinating with payers, enrolling patients in financial assistance programs, and ensuring timely approvals to avoid treatment delays.
Core Behavioral Values
CLEAR ID : Collaborate, Learn, Empathy, Accountable, Respect, Integrity, Dedication
These behaviors are based on Eyesight’s culture and values critical to support the organization’s mission of providing uncompromising care to patients.
Essential Functions
Review retina clinic schedules to identify patients requiring prior authorizations
Verify insurance eligibility and benefit details for injectable medications and procedures
Obtain all necessary prior authorizations for retina injections, ensuring appropriate ICD-10, CPT, and HCPCS codes are submitted
Submit supporting clinical documentation, including notes, diagnostics, and test results, to facilitate approvals
Track, follow up on, and document all pending and retro-authorization requests
Maintain accurate logs of prior authorization statuses, expiration dates, and coverage limitations
Coordinate and apply for manufacturer-sponsored copay or patient assistance programs for eligible patients
Confirm that all prior authorization and financial assistance outcomes are documented in the PM/EMR system
Upload and maintain updated insurance and authorization documentation
Collaborate with retina technicians and schedulers to ensure patients are cleared for treatmentCommunicate with payors to resolve issues related to delays or denials.
Appeal denied authorizations as appropriate
Maintain current knowledge of payer-specific rules for specialty drugs and retina procedures
Assist with insurance verification and accurate plan entry when discrepancies are found
Support patients during checkout, especially for financial discussions related to treatment plans
Answer clinic and patient questions related to billing, coverage, and assistance programs
Qualifications
2+ years in a medical office setting
Strong knowledge of insurance verification, prior authorizations and specialty drug coverage – ophthalmology or retina experience strongly preferred
Understanding of CPT/ICD-10 and HCPCA coding
Strong analytical, problem-solving, and organizational skills
Excellent written and verbal communication skills
Preferred
Proficiency in EMR/PM systems (experience with ModMed a plus)
Knowledge of HIPAA and patient privacy standards
Work Conditions
Professional healthcare setting, including clinics, administrative areas, and patient-facing environments
Noise level ranges from quiet to moderate, depending on location and activity
Potential exposure to infectious diseases, bodily fluids, or cleaning agents in accordance with standard protocols
Physical Requirements
Ability to sit, stand, and walk for extended periods
Frequent use of hands and fingers to operate medical or office equipment
Clear verbal and written communication; ability to hear and understand speech in person and by phone
Close vision required for reading small print and viewing computer screens
Occasional lifting or moving of objects up to 25 pounds
May involve reaching, bending, stooping, kneeling, or other physical movement
Ability to manage multiple priorities and maintain professional interactions in a dynamic setting
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Core Behavioral Values
CLEAR ID : Collaborate, Learn, Empathy, Accountable, Respect, Integrity, Dedication
These behaviors are based on Eyesight’s culture and values critical to support the organization’s mission of providing uncompromising care to patients.
Essential Functions
Review retina clinic schedules to identify patients requiring prior authorizations
Verify insurance eligibility and benefit details for injectable medications and procedures
Obtain all necessary prior authorizations for retina injections, ensuring appropriate ICD-10, CPT, and HCPCS codes are submitted
Submit supporting clinical documentation, including notes, diagnostics, and test results, to facilitate approvals
Track, follow up on, and document all pending and retro-authorization requests
Maintain accurate logs of prior authorization statuses, expiration dates, and coverage limitations
Coordinate and apply for manufacturer-sponsored copay or patient assistance programs for eligible patients
Confirm that all prior authorization and financial assistance outcomes are documented in the PM/EMR system
Upload and maintain updated insurance and authorization documentation
Collaborate with retina technicians and schedulers to ensure patients are cleared for treatmentCommunicate with payors to resolve issues related to delays or denials.
Appeal denied authorizations as appropriate
Maintain current knowledge of payer-specific rules for specialty drugs and retina procedures
Assist with insurance verification and accurate plan entry when discrepancies are found
Support patients during checkout, especially for financial discussions related to treatment plans
Answer clinic and patient questions related to billing, coverage, and assistance programs
Qualifications
2+ years in a medical office setting
Strong knowledge of insurance verification, prior authorizations and specialty drug coverage – ophthalmology or retina experience strongly preferred
Understanding of CPT/ICD-10 and HCPCA coding
Strong analytical, problem-solving, and organizational skills
Excellent written and verbal communication skills
Preferred
Proficiency in EMR/PM systems (experience with ModMed a plus)
Knowledge of HIPAA and patient privacy standards
Work Conditions
Professional healthcare setting, including clinics, administrative areas, and patient-facing environments
Noise level ranges from quiet to moderate, depending on location and activity
Potential exposure to infectious diseases, bodily fluids, or cleaning agents in accordance with standard protocols
Physical Requirements
Ability to sit, stand, and walk for extended periods
Frequent use of hands and fingers to operate medical or office equipment
Clear verbal and written communication; ability to hear and understand speech in person and by phone
Close vision required for reading small print and viewing computer screens
Occasional lifting or moving of objects up to 25 pounds
May involve reaching, bending, stooping, kneeling, or other physical movement
Ability to manage multiple priorities and maintain professional interactions in a dynamic setting
#J-18808-Ljbffr