Sr Representative Customer Service Operations Prior Authorization

Position Summary

This role is responsible for processing prior authorization requests efficiently while adhering to payer guidelines and policies.

Essential Functions

• Handles complex prior authorization requests, including high-cost medications and procedures.
• Serves as a point of contact for escalated authorization issues.
• Assists in reviewing insurance policies to ensure compliance with payer requirements.
• Coordinates with healthcare providers and insurance companies to resolve discrepancies.
• Ensures timely submission and follow-up on authorization requests.
• Reviews incoming authorization requests and verifies patient eligibility and benefits.
• Initiates prior authorization requests via phone, fax, or online portals.
• Tracks and follows up on the status of submitted authorizations.
• Communicates approval or denial outcomes to healthcare providers and patients.
• Maintains accurate records and documentation of all authorization activities.
• Collaborates with the billing and clinical teams to ensure accuracy of information.
• Complies with HIPAA rules, appropriately safeguarding PHI or other private & confidential information.
• Maintains accurate and detailed notes in the company system.
• Adapts quickly to frequent process changes and improvements.
• Is reliable, engaged, and provides feedback to improve processes and policies.
• Attends all department, team, and weekly company meetings as required.
• Appropriately routes incoming calls when necessary.
• Meets company quality standards.
• Embraces and exemplifies ADS core values: