Authorization & Billing Specialists

Job Description

Job Description

Ophthalmic Consultants if Boston is currently looking for Authorization Billing Specialists to join our team in Plymouth. These specialists provide administrative and billing support to the Retina team and serves as a responsive, accurate resource for providers and clinical staff as to coverage of various treatment options. Develops and maintains strong rapport with providers and clinical staff to ensure effective collaboration, communication, and mutual trust.

The work schedule is Monday through Friday 8-4:30PM and can be fully onsite or a hybrid schedule once trained.

Examples of Duties:

· Maintains accurate, up-to-date understanding of payer policies for Retina injectable medications, including policy changes as they occur.

· Consistently maintains an effective tracking tool for active Prior Authorizations (PA) and their expirations dates to anticipate PAs that need renewal.

· Proactively submits PA requests and appropriate supporting documentation as needed for upcoming appointments with sufficient lead time so that PA can be obtained prior to patients’ appointments.

· Submits urgent PA requests as needed, e.g., in the event of adding on patients.

· Effectively communicates with “challenging” insurance companies to ensure prior approval and coverage.

· Consistently and methodically saves PA approval to patient record in Epic and updates Permanent Comments field in Epic to communicate to provider and clinic team the status of PA approval.

· Promptly and effectively addresses denied PAs to ensure approval is ultimately obtained.

· Reviews periodic reports for outstanding patient balances to identify the need for connecting patients with copay support services.

· Registers commercially insured patients with manufacturer copay support services

· Registers Medicare and Medicare Advantage patients with foundation copay support services

· Orders specialty pharmacy (SP) medication, as required, and carefully communicates with clinic team the related billing procedures for SP.

· Manages and reviews the daily EPIC schedule, utilizing the Day in Accounts Receivable (DAR) to ensure that all scheduled retina/procedure appointments are verified for coverage, drug, authorization, and balance.

Performance Requirements:

· Knowledge of organizational policies, procedures, and systems

· Ability to exercise initiative, problem solving and decision making.

· Must be highly organized, accurate, and proactive, with strong reasoning ability.

· Excellent written and verbal communication skills.

· Familiar with retinal diseases, the symptoms, and treatments strongly preferred/required (?)

· Knowledgeable about retinal medications and therapies, e.g., class of drug, approved indications, off label usage, risks, benefits, and alternatives strongly preferred.

· Able to read and understand ophthalmic/retina office notes including exam documentation, assessment, and plan, and to understand provider’s decision-making based on the documentation.

· Prior experience with standard operations of insurance companies; verification of benefits/coverage including prior authorization (PA), claims, approvals, denials, appeals, letters of medical necessity, peer-to-peer discussions, buy-and-bill vs. specialty pharmacy processes, co-pays, deductibles, and payer coverage policies, etc.

· Familiar with medication manufacturers’ portals/hubs and how to use them.

· Familiar with required injection paperwork including consent forms, manufacturers’ portal registration forms, ABNs and NEIBs, etc.

· Strong working knowledge with properly coding services, procedures, diagnosis, and treatments (ICD10 and CPT coding)

· Communicate with patients to discuss procedures, insurance coverage, prior authorization and assisting patients with various questions.

· Assist Billing management with implementing production, productivity, quality, resolving problems and identifying billing system improvements.

· Updates job knowledge by participating in educational opportunities; reading professional publications, payer webinars.

· Maintains strictest discretion and confidentiality.

· Other duties as assigned.

Education and Experience:

· Associate degree in Business Administration or equivalent Medical Billing Experience.

· Bachelor’s degree preferred.

· 3+ years of medical billing experience.

· Prior experience in ophthalmology strongly preferred.

· Previous experience with Epic required.

OCB offers industry leading benefits including the 401(k) and great medical and dental benefits. To find out more about OCB, please visit our website at

OCB is an Equal Opportunity Employer.

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