Job Description

We are seeking a detail-oriented, high-performing Revenue Cycle & Authorizations Specialist to manage patient eligibility, obtain prior authorizations, and drive accounts receivable (AR) recovery.

This role manages a core volume of approximately 200 claims per week, with a primary focus on navigating and resolving complex claim denials, prior authorization hurdles, and payer issues associated with two major HMO plans. The ideal candidate thrives on problem-solving, possesses strong payer navigation skills, and excels at keeping practice revenues steady and predictable.

Requirements

Primary Responsibilities

Accounts Receivable & Denials Management

• Manage end-to-end follow-ups on unpaid, underpaid, and denied claims across accounts receivable (AR) aging reports.
• Serve as the dedicated specialist for two high-priority HMO plans—actively researching rejection reasons, resubmitting corrected claims, filing appeals, and escalating administrative roadblocks.
• Process routine Medicare and PPO denials swiftly to ensure low aging across simpler payer types.
• Process, track, and reconcile approximately 200 claims per week.

Authorizations & Insurance Verification

• Perform insurance eligibility and coverage verifications prior to patient appointments.
• Submit, track, and secure prior authorizations from commercial and managed care payers to prevent coverage gaps and claim rejections.
• Maintain clear communication with clinical staff regarding authorization statuses, limitations, and approval updates.

Payer & Patient Communication

• Place high-volume follow-up calls to HMO representatives, medical groups, and clearinghouses to clear claim holds.
• Communicate politely and clearly with patients regarding insurance coverage rules, outstanding balances, or required authorization steps.

Qualifications & Key Requirements

• Experience: 2+ years of experience in medical billing, accounts receivable management, and insurance prior authorizations.
• HMO Expertise: Strong working knowledge of HMO medical group referrals, capitation/FFS structures, and HMO-specific appeal pathways.
• Coding & Billing Knowledge: Working knowledge of CPT, ICD-10, HCPCS codes, modifiers, and CMS-1500 claim formats.
• Volume Capability: Proven ability to manage a consistent workload of ~200 claims per week without sacrificing accuracy.
• Reliability: High level of punctuality and commitment to maintaining the established 38-hour weekly work schedule.