Eligibility Authorization Representative
Full Time
Altadena, CA
Posted
Job description
Planned Parenthood Pasadena & San Gabriel Valley (PPPSGV) has been proudly serving our community since 1933 and is one of the original Planned Parenthood affiliates in the nation.
We provide reproductive health care, health education and advocacy from our five health centers in
Alhambra, Baldwin Park, Glendora, Highland Park, and Pasadena, in addition to our telehealth clinic. We strive to ensure the sexual and reproductive health services we provide align with the needs of the communities we serve. Our service area extends from Glendora to Glendale and from the San Gabriel mountains to the San Bernardino freeway, home to 24 communities and a diverse population of 1.4 million people.
Today, PPPSGV sees over 60,000 patient visits per year and delivers over 15,000 opportunities for sex and relationship education in our schools and colleges.
We offer safe and legal abortions. We are committed to providing accurate, non-judgmental care and resources by helping our patients overcome financial, transportation, and other barriers to care. In addition, we work with abortion funds and practical support network to support our patients. Our abortion care has increased every year since 2018 with an average of 3,500 abortions per year. We saw close to 4,000 abortion patients in 2022 alone, approximately 59 were out-of-state patients.
The Eligibility Authorization Representative will ensure accurate eligibility, verification and authorization benefits to allow for clean claim submission and accurate patient collections.
As an Eligibility Authorization Representative, you make a difference as you:
- Verify insurance coverage and benefits with respective insurance companies and file all necessary forms for pre-certifications, and referral requests, if applicable
- Submit Good Faith Estimates to our patients in accordance with the Federal No Surprise Act guidelines
- Organize and track upcoming appointments by working with daily scheduling reports and Health Center staff
- Provide excellent customer service and acceptable responsiveness: typical expectation is response within 48 hours or receipt of request to all departments
- Review accounts for completeness of insurance information, for the necessity of referrals, pre-certifications, and prior authorizations to ensure reimbursement at the highest level possible
- Verify, update, and enter insurance information into the electronic practice management system (EPM) including policy information, benefit coverage, and referrals
- Identify any potential non-coverage issues and effectively communicate this information to our health center and patients
- Provide timely responses to voicemail and email inquiries to the verification team
- Participate in regular team meetings; provide positive feedback and suggestions
- Handle receipt and data entry of incoming prior authorization requests, including patient consent forms and patient medical records, promptly to third party payers
- Review and ensure all necessary documentation are provided to file a prior authorization, a pre-service appeal, or an external review, when necessary
- Gather required/additional supporting documentation and information, including state protocols, physician or hospital medical records, state or federal statutes, patient, or physician letters of medical necessity, etc.
- Submit requests to independent review organizations for external review appeals with collected clinical materials, letters, and reference materials
- Follow through with payer correspondence and requests for more information related to each authorization
- Conduct informative and educational interactions with utilization review and management departments at insurance companies and independent review organizations.
- Communicate with physician offices and staff/clinical contacts on the progress of their prior authorization or internal appeal requests
- Manage multiple priorities and deadlines successfully, while handling stressful situations accordingly
- Ensure compliance with company policies, specifically patient confidentiality (HIPAA) in all Mainstay Medical practices
- Models PPPSGV values through demonstrated behavior, action, and words. Supports the mission, vision and values of the organization providing the highest level of customer service to patients, providers and team members
- Perform other duties, as required
We are looking for someone with the following qualifications:
- Experience:
- Minimum of 2 years’ experience in a medical office or payer with eligibility/verification and prior authorization experience or utilization review with emphasis in Managed Medi-cal, including downstream delegation
Other:- Ability to work night and weekend shifts to support health center operations
- Practice management software experience, NextGen experience a plus
- Knowledge of health insurance industry practices and functions
- Experience with Medicare, Medicaid, Medicaid Managed Plans and Commercial Insurance
- Superior oral and written communication skills
- Demonstrates excellent organization skills with attention to detail
- Proficient in Microsoft Office, including Microsoft Word, Outlook, Excel, and PowerPoint
- Experience working with platforms such as Clearinghouse, Availity, eFax systems, and other basic database management programs
- Problem solver and capable to find solutions to challenges or process impediments.
- Maintains a caring, empathetic, and patient-centric approach in all interactions
- Commitment to personal and/or organizational Diversity, Equity and Inclusion work
- Commitment to the mission of Planned Parenthood
The hiring rate for this position is: $22 - $25/hour or year + Medical, Dental, Vision, 401k Matching Program, Premium CALM account, holidays, paid time off, and more!
PPPSGV is committed to fostering an inclusive and diverse workplace. We offer a series of workshops during employee onboarding and throughout the year. We also provide additional opportunities to get involved in our diversity, equity, and inclusion (DEI) work through various task forces, conferences, and staff retreats.
We are a prominent team of passionate health experts who adhere to the highest standards as we collaborate and care for people without judgment. As we stand in solidarity with communities of color, we demand greater diversity, equity and inclusion (DEI) within our organization.
Join our team and be part of a powerful movement to shape the future of sexual and reproductive health!
Planned Parenthood Pasadena & San Gabriel Valley is an Equal Opportunity Employer.
Please visit our careers page for more information: Careers at PPPSGV | Planned Parenthood Pasadena & San Gabriel Valley
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