Eyesight Ophthalmic Services
Prior Authorization Representative - Retina
Eyesight Ophthalmic Services, Somersworth, New Hampshire, us, 03878
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. Requirements
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 treatment Communicate 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
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. Requirements
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 treatment Communicate 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