Eligibility and Prior Authorization Specialist

Responsible for building and maintaining collaborative relationships with internal and external stakeholders to support eligibility verification and prior authorization processes. This role involves managing revenue cycle projects, driving operational performance related to reimbursement, and overseeing processes impacting cash collections. Primary responsibilities include conducting thorough prior authorization case reviews and follow-ups, ensuring all attempts are exhausted before escalating to vendors and/or internal teams. Accurately documenting all authorization activities, follow-ups, and outcomes in the designated systems and trackers. Addressing denied or delayed authorizations by investigating issues, providing necessary documentation, and submitting appeals as required. The Eligibility and Prior Authorization Specialist will exercise critical thinking to evaluate case statuses, identify escalation triggers, and route unresolved issues to appropriate teams or vendors. Serve as a source of knowledge for the designated revenue cycle function. Perform analysis, identify trends, and prioritize initiatives for performance improvement in the designated revenue cycle area. Establish ongoing working relationships with other departments that impact revenue cycle performance. Additionally, work closely with various vendor operations teams (Prior Authorization, Claims, and Appeals) to oversee operations activity and ensure timely and accurate processing for optimal reimbursement.