1. Secure prior authorizations for a variety of pediatric services.
2. Verify insurance eligibility and benefits prior to service; ensure benefits and authorizations are clearly documented in the patient record.
3. Gather, verify, and review the necessary clinical documentation from providers, including medical records, progress notes, lab results, treatment plans, and any other require information to ensure requested services meeting payer medical necessity requirements based on CPT codes provided.
4. Coordinate with clinical and scheduling teams to prevent delays in care caused by pending or denied authorizations.
5. Participate in clinical huddles and team meetings to discuss challenges, share best practices, and contribute to process improvement initiatives.
6. Follow-up with payers to obtain timely approvals and resolve issues related to pediatric-specific criteria (e.g., age-based guidelines, developmental appropriateness).
7. Communicate denied authorizations and next steps to initiate the peer to peer or appeal process, track and manage the outcomes, and escalate any issues.
8. Refer families to Financial Counseling when patient responsibility amounts are identified and provide clear guidance to support caregiver understanding.
9. Maintain accurate records of authorization statuses and payer communications in the EHR.
10. Collaborate with care teams, including case management, to expedite authorizations for urgent services when needed.
11. Meet departmental standards for productivity, accuracy, and timeliness.

1. Knowledge of medical terminology, CPT/ICD-10 codes, and pediatric insurance benefits.
2. Strong interpersonal communication skills to support families with empathy and clarity.
3. Ability to navigate multiple systems (EHR, payer portals); Epic experience preferred.
4. Understanding of medical necessity and documentation standards for pediatric services.

Education and Experience

1. Education: High school diploma or equivalent required; associate degree or healthcare certification preferred.
2. Experience: Minimum 1 year in a Clinical, Revenue Cycle, Patient Access or Insurance company role that perform work related to; prior authorization, insurance verification, billing, scheduling, patient service rep, customer service, etc. required.
3. Pediatric healthcare access roles preferred.
4. Working with pediatric patients, families, or within a children's hospital preferred.
5. Familiarity with pediatric insurance policies, including Medicaid, managed care, and commercial plans preferred.