Prior Authorization & Eligibility Specialist

Essential Duties & Responsibilities

• Verify patient insurance eligibility before scheduled services.
• Confirm active coverage and effective dates.
• Verify patient demographics and insurance information.
• Verify primary and secondary insurance coverage.
• Identify coordination-of-benefits issues.
• Verify provider participation/network status when appropriate.
• Review payer-specific requirements.
• Determine whether prior authorization is required.
• Determine whether a referral is required.
• Submit prior authorization requests.
• Obtain and submit supporting clinical documentation as required.
• Follow up with insurance companies regarding pending authorization requests.
• Track authorization status through determination.
• Document authorization numbers, effective dates, approved services/units, and expiration dates.
• Monitor existing authorizations to prevent expiration or exhaustion of approved visits/units.
• Coordinate referral requirements.
• Communicate authorization or eligibility problems to the client before services whenever possible.
• Maintain accurate documentation of all verification and authorization activities.

Benefits Verification

The Patient Access Specialist may verify:

• Deductibles
• Copayments
• Coinsurance
• Out-of-pocket amounts
• Coverage limitations
• Service-specific benefits
• Visit limitations
• Authorization requirements
• Referral requirements
• Network requirements
• Primary/secondary payer information

The employee must accurately document information obtained from payer portals or insurance representatives and avoid representing benefit verification as a guarantee of payment.

Prior Authorization

Responsibilities include:

• Determine whether authorization is required.
• Initiate authorization requests.
• Submit required documentation.
• Communicate with payer utilization management departments.
• Follow up on pending authorizations.
• Track authorization decisions.
• Document authorization/reference numbers.
• Track approved CPT/services when applicable.
• Track approved visits or units.
• Track authorization effective and expiration dates.
• Request extensions or additional visits when appropriate.
• Escalate authorization denials requiring clinical review or appeal.
• Notify the appropriate client/team when services are not authorized.

Denial Prevention

A major responsibility of this position is preventing avoidable denials before claims are submitted.

The Patient Access Specialist should identify potential issues involving:

• Inactive insurance
• Incorrect member information
• Incorrect payer
• Coordination of benefits
• Missing prior authorization
• Expired authorization
• Exhausted visits/units
• Missing referral
• Out-of-network provider
• Service exclusions
• Benefit limitations
• Incorrect provider/service location information

Issues should be communicated promptly to the appropriate client or AdvantixxRCM department.

Internal Coordination

The Patient Access Specialist works closely with the:

Medical Billing Specialist for claim-related insurance information.

A/R Specialist for eligibility-related unpaid claims.

Denial Management Specialist for authorization and eligibility denials.

Credentialing Specialist for provider participation/enrollment concerns.

Client Account Manager for information needed from healthcare clients.

Operations Manager for escalated issues and payer trends.

Required Qualifications

• Minimum 1–2 years of healthcare insurance verification, prior authorization, medical billing, patient access, or RCM experience preferred.
• Experience verifying insurance eligibility and benefits.
• Experience obtaining prior authorizations.
• Familiarity with Medicare, Medicaid, Medicare Advantage, Medicaid Managed Care, and commercial insurance.
• Experience using insurance payer portals.
• Understanding of healthcare insurance terminology.
• Knowledge of deductibles, copayments, coinsurance, and out-of-pocket responsibilities.
• Strong organizational and follow-up skills.
• Excellent attention to detail.
• Strong written and verbal communication.
• Ability to manage multiple pending authorizations and deadlines simultaneously.

Preferred Qualifications

• Previous RCM or medical billing company experience.
• Experience with multiple healthcare specialties.
• Experience with Availity and other payer portals.
• Familiarity with CPT/HCPCS terminology.
• Experience working with Medicare and Medicaid.
• Experience handling referrals.
• Experience with medical necessity documentation.
• Bilingual English/Spanish is a plus.

Performance Expectations

Performance will be evaluated based on:

• Eligibility verification accuracy
• Prior authorization completion
• Authorization turnaround
• Follow-up timeliness
• Documentation accuracy
• Authorization tracking
• Prevention of eligibility/authorization-related denials
• Productivity
• Client communication
• Compliance with payer requirements

What We're Looking For

We are looking for someone who understands that successful revenue cycle management begins before the claim is submitted.

The Patient Access Specialist should proactively identify insurance, eligibility, authorization, and referral issues so they can be addressed before they become denials or lost revenue.

We need someone who takes ownership of pending authorizations and does not consider the job finished simply because an authorization request was submitted.

Why Join AdvantixxRCM?

AdvantixxRCM is building a comprehensive revenue cycle organization focused on improving reimbursement while preventing avoidable revenue loss for healthcare providers.

We value accuracy, accountability, urgency, communication, and problem-solving.

About AdvantixxRCM

AdvantixxRCM is a healthcare revenue-cycle management company supporting medical practices and healthcare organizations with accurate, compliant, and service-focused billing operations. Our culture values ethical billing, patient-conscious service, accuracy, ownership, respectful collaboration, continuous improvement, privacy, security, and speaking up.

Team members protect confidential patient and client information, use only authorized systems, and follow company, client, payer, HIPAA, and applicable legal requirements. AdvantixxRCM is an equal opportunity employer.