Lead Insurance Authorization Specialist

Under limited supervision, the Lead Insurance Authorization Specialist coordinates the workload, and execution of the financial clearance process for scheduled and nonscheduled appointments. This role ensures services are financially cleared days in advance of care to optimize reimbursement and minimize financial risk. The Lead provides mentorship to the team while actively performing complex clearance duties, including verifying eligibility, securing authorizations, researching procedure codes, conducting financial work-ups, and managing pre-service collections.

Essential Job Functions

• Monitor, balance, and distribute daily tasks within the client and supervisor work queues to ensure team productivity targets are met.
• Act as the first-line escalation point for team members facing complex payer authorization roadblocks or technical system issues.
• Complete eligibility checks and verify coverage for inpatient and outpatient, scheduled and nonscheduled visits via phone or electronic payer systems. Provide initial clinical documentation to carriers when requested.
• Review, initiate, and secure pre-certifications and authorizations with physicians, PHO sites, or insurance companies.
• Work with insurance companies to obtain retroactive authorizations for services already rendered and collaborate with providers, coders, and case management to appeal denied claims.
• Contact patients, families, and physicians to collect, analyze, and record accurate demographic, clinical, and financial data. Conduct financial work-ups, arrange phone collections/pre-service payments, and communicate pertinent data to financial counselors.
• Adhere to all corporate policies, procedures, and regulatory standards, including EMTALA, HIPAA, and HIPAA HITECH.
• The duties listed above are representative of the role, and an individual may be responsible for performing all, or a specific subset, of these functions. Additionally, individual may be required to perform other related tasks and responsibilities as applicable or assigned to meet operational and client needs.

Key Success Indicators/Attributes

• Adept at multi-tasking, setting deadlines, and prioritizing a variety of tasks independently, often shifting assignments on short notice in a fast-paced environment.
• Strong analytical and critical thinking skills to resolve complex registration or insurance issues, utilize accurate judgement, and meet production metrics.
• Excellent verbal, listening, and written communication skills to build trust, maintain credibility, and remain composed during stressful situations.
• Perform data entry with accuracy while safeguarding corporate and client assets, proactively reporting any security compromises.
• Skill in operating a computer and learning multiple software or hardware systems concurrently within an average workday.

Supervisory Responsibility

No

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• High School diploma or equivalent.
• Minimum 2 years of experience in a hospital patient access/patient accounts department, medical office/clinic, or insurance company environment.
• Proven experience interacting professionally with patients, alongside working knowledge of third-party payers, collections, and navigating electronic insurance verification/eligibility systems.
• Strong baseline knowledge of medical and insurance terminology.

Preferred Education and Experience

• Associate’s degree.
• Knowledge of ICD-9 and ICD-10 coding conventions and CPT codes.

• Familiarity with rules established by AHIMA, the American Medical Association (AMA), the American Hospital Association (AHA), and the Center for Medicare and Medicaid Services (CMS).

Additional Eligibility Qualifications

N/A

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. Employee may perform other duties as assigned.