Insurance Navigator (Pre-Authorization)

Department: Business Development

Reports To: Call Center Manager

The Clinical Patient Navigator assists patients in getting approval for necessary medical services by guiding them through the pre-authorization process. This role uses organizational and communication skills to help patients, work with healthcare providers and insurance companies, and ensure a smooth path to their care. The Clinical Patient Navigator is a key contact for patients needing pre-authorization, offering support and clear information.

Essential Functions:

• Pre-Authorization Support:
  • Help process pre-authorization requests for different medical services like procedures (inpatient, outpatient, same day surgery), tests(all kind of radiology), and medications.
  • Understand and follow the rules of different insurance companies for getting approvals.
  • Able to navigate and utilized diverse insurance's portals to obtain and or initiated pre-authorization for specific procedures.
  • Enter patient and medical information accurately into computer systems.
  • Help gather necessary paperwork from doctor's offices.
  • Follow up on pre-authorization requests to avoid delays.
  • Share the results of the pre-authorization with patients and the healthcare team clearly.
  • Learn about different insurance plans and their pre-authorization rules.
• Patient Guidance:
  • Be a main point of contact for patients with pre-authorization questions, offering friendly support.
  • Explain the pre-authorization process to patients and their rights.
  • Help patients understand what their insurance might cover and any potential costs.
  • Answer patient questions and concerns politely and get help for more complex issues.
  • Connect patients, doctors' offices, and insurance companies to help resolve pre-authorization issues.
• Teamwork and Communication:
  • Work well with doctors, nurses, and other healthcare staff to get needed medical information.
  • Communicate clearly with insurance companies to get timely approvals.
  • Work with billing departments to ensure correct processing of claims.
  • Participate in team meetings to improve how pre-authorizations are handled.
• Record Keeping and Following Rules:
  • Keep accurate and complete records of all pre-authorization work following all guidelines.
  • Protect patient privacy according to HIPAA rules.
  • Report any possible issues or trends related to pre-authorization.

Qualifications:

• High school diploma or equivalent required.
• Associate's degree in Healthcare Administration or a related field is preferred.
• Experience with medical billing & EMR System a requirement.
• Bilingual in Spanish is a plus.
• Good communication and customer service skills.
• Ability to organize information and pay attention to detail.
• A desire to help patients navigate their healthcare.
• Microsoft suite(Excel, Word, outlook) experience a requirement.

Physical Requirements:

• Requires extensive periods of sitting at a desk.
• Requires frequent and repetitive typing and computer use.

Working Conditions:

• Fast-paced work environment with deadlines.