Performance Ortho
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$60,000.00/yr - $70,000.00/yr Human Resources Business Partner | Talent Acquisition Management | Candidate Experience | Employee Relations | Business Operations | ATS | HRIS |…
Job Overview: About Us Performance Ortho is a leading provider of comprehensive orthopedic and outpatient care in New Jersey. With four clinic locations, an Ambulatory Surgery Center, and our corporate headquarters in Bridgewater, we’re celebrating 24 years of growth and excellence. Our holistic approach includes a wide array of services—Chiropractic, Physical Therapy, Acupuncture, Occupational Therapy, and Orthopedic Surgery—all aimed at delivering the highest quality of patient care. We pride ourselves on fostering a collaborative, supportive work environment where our team members are empowered to thrive and grow. Eligibility and Authorization Lead
is responsible for overseeing the verification of patient information, determining eligibility for services and benefits, and securing necessary authorizations for procedures and treatments across government, commercial, and third-party payers. This leadership role ensures accurate and timely eligibility determinations while ensuring compliance with policies, regulations, and industry standards. The Lead will work closely with internal teams, external vendors, and insurance providers to resolve discrepancies, streamline processes, and maintain data integrity. A comprehensive understanding of Medicare, Medicare Advantage, private and commercial insurance plans is essential for success in this role. Key Responsibilities: 1. Verification & Eligibility Determination Lead the verification of patient identity, insurance coverage, and eligibility for services. Oversee the determination of eligibility across government, commercial, and third-party payers. Ensure that all eligibility determinations are made in compliance with regulations and organizational policies. Train and guide the team in effectively utilizing eligibility verification systems. 2. Authorization & Approval Process Supervise the process of obtaining pre-authorizations for medical procedures, treatments, and services. Communicate with healthcare providers, insurance companies, and internal teams to ensure timely and accurate authorization approvals. Monitor and ensure the timely processing of authorizations to prevent service delays or denials. Provide leadership in developing best practices to streamline authorization processes across multiple specialties. 3. Compliance & Quality Assurance Ensure adherence to compliance standards for Medicare, Medicare Advantage, private insurance plans, and other third-party payer policies. Oversee audits and quality assurance checks to maintain accuracy and minimize errors in eligibility and authorization processes. Stay up to date with industry regulations and payer policies, ensuring the team is properly trained on any changes. 4. Stakeholder Communication & Issue Resolution Lead collaboration efforts with internal teams, external vendors, and insurance providers to resolve eligibility and authorization discrepancies. Provide clear communication regarding eligibility determinations and authorization decisions to both internal and external stakeholders. Supervise the handling of denied authorizations, including appeals and resolutions. Act as the primary escalation point for complex issues related to verification and authorization. 5. Data Management & Reporting Ensure accurate documentation of verification and authorization details in electronic health records (EHR) and other relevant systems. Maintain data integrity and safeguard patient confidentiality in all transactions. Review daily eligibility reports and authorization approvals/denials, and process efficiencies for management review. Analyze data to identify opportunities for process improvement. Qualifications: Education : High school diploma or equivalent required; an associate degree in healthcare administration or a related field is preferred. Experience : Minimum 5 years of experience in eligibility verification, authorization management, medical billing, or payment posting, ideally within a multi-specialty or orthopedic setting. Strong experience with government, private and commercial payer policies. Prior leadership experience in managing teams, with a focus on process improvement and training. Experience with Patient Accounts Collections within Orthopedics Certifications : Relevant certifications in healthcare or insurance (e.g., Certified Health Insurance Specialist, Certified Medical Reimbursement Specialist) are a plus. Technical Skills : Familiarity with electronic health records (EHR) systems, eligibility platforms, and billing software. Proficiency in Microsoft Office Suite, particularly Excel, for reporting and data analysis. Knowledge of Payers : Strong understanding of Medicare, Medicare Advantage, private and commercial insurance payer policies.
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$60,000.00/yr - $70,000.00/yr Human Resources Business Partner | Talent Acquisition Management | Candidate Experience | Employee Relations | Business Operations | ATS | HRIS |…
Job Overview: About Us Performance Ortho is a leading provider of comprehensive orthopedic and outpatient care in New Jersey. With four clinic locations, an Ambulatory Surgery Center, and our corporate headquarters in Bridgewater, we’re celebrating 24 years of growth and excellence. Our holistic approach includes a wide array of services—Chiropractic, Physical Therapy, Acupuncture, Occupational Therapy, and Orthopedic Surgery—all aimed at delivering the highest quality of patient care. We pride ourselves on fostering a collaborative, supportive work environment where our team members are empowered to thrive and grow. Eligibility and Authorization Lead
is responsible for overseeing the verification of patient information, determining eligibility for services and benefits, and securing necessary authorizations for procedures and treatments across government, commercial, and third-party payers. This leadership role ensures accurate and timely eligibility determinations while ensuring compliance with policies, regulations, and industry standards. The Lead will work closely with internal teams, external vendors, and insurance providers to resolve discrepancies, streamline processes, and maintain data integrity. A comprehensive understanding of Medicare, Medicare Advantage, private and commercial insurance plans is essential for success in this role. Key Responsibilities: 1. Verification & Eligibility Determination Lead the verification of patient identity, insurance coverage, and eligibility for services. Oversee the determination of eligibility across government, commercial, and third-party payers. Ensure that all eligibility determinations are made in compliance with regulations and organizational policies. Train and guide the team in effectively utilizing eligibility verification systems. 2. Authorization & Approval Process Supervise the process of obtaining pre-authorizations for medical procedures, treatments, and services. Communicate with healthcare providers, insurance companies, and internal teams to ensure timely and accurate authorization approvals. Monitor and ensure the timely processing of authorizations to prevent service delays or denials. Provide leadership in developing best practices to streamline authorization processes across multiple specialties. 3. Compliance & Quality Assurance Ensure adherence to compliance standards for Medicare, Medicare Advantage, private insurance plans, and other third-party payer policies. Oversee audits and quality assurance checks to maintain accuracy and minimize errors in eligibility and authorization processes. Stay up to date with industry regulations and payer policies, ensuring the team is properly trained on any changes. 4. Stakeholder Communication & Issue Resolution Lead collaboration efforts with internal teams, external vendors, and insurance providers to resolve eligibility and authorization discrepancies. Provide clear communication regarding eligibility determinations and authorization decisions to both internal and external stakeholders. Supervise the handling of denied authorizations, including appeals and resolutions. Act as the primary escalation point for complex issues related to verification and authorization. 5. Data Management & Reporting Ensure accurate documentation of verification and authorization details in electronic health records (EHR) and other relevant systems. Maintain data integrity and safeguard patient confidentiality in all transactions. Review daily eligibility reports and authorization approvals/denials, and process efficiencies for management review. Analyze data to identify opportunities for process improvement. Qualifications: Education : High school diploma or equivalent required; an associate degree in healthcare administration or a related field is preferred. Experience : Minimum 5 years of experience in eligibility verification, authorization management, medical billing, or payment posting, ideally within a multi-specialty or orthopedic setting. Strong experience with government, private and commercial payer policies. Prior leadership experience in managing teams, with a focus on process improvement and training. Experience with Patient Accounts Collections within Orthopedics Certifications : Relevant certifications in healthcare or insurance (e.g., Certified Health Insurance Specialist, Certified Medical Reimbursement Specialist) are a plus. Technical Skills : Familiarity with electronic health records (EHR) systems, eligibility platforms, and billing software. Proficiency in Microsoft Office Suite, particularly Excel, for reporting and data analysis. Knowledge of Payers : Strong understanding of Medicare, Medicare Advantage, private and commercial insurance payer policies.
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