Revenue Cycle Specialist II

About the Role:

As a Revenue Cycle Specialist II - Surgery Authorization Specialist, you will play a key role in ensuring timely insurance verification, benefits review, and securing required pre-certifications, authorizations, and referrals prior to surgical services. This role plays a key part in the revenue cycle by ensuring timely approvals, accurate documentation, and clear communication with patients, payers, and clinical teams. This position requires advanced knowledge of medical billing practices, insurance reimbursement guidelines, medical coding, and collection regulations. You will be responsible for resolving complex authorization related issues, leveraging a thorough understanding of company policies and medical payor policies to optimize the revenue cycle processes. 

What You’ll Do:

• Verify insurance eligibility and benefits prior to scheduled surgical services.
• Review, submit, and track surgical authorization and pre-certification requests.
• Communicate with insurance carriers via payer portals and phone to obtain approvals, authorizations, predeterminations and referral as needed.
• Interpret payer medical policies and clinical guidelines to confirm medical necessity.
• Calculate and communicate estimated patient financial responsibility prior to surgery.
• Monitor authorization requests through final determination and follow up on pending cases.
• Collaborate with clinical staff, surgery schedulers, and revenue cycle teams to resolve authorization issues or denials.
• Support escalation cases, including coordination of peer-to-peer reviews when required.
• Accurately document authorization activity and payer communication in the EMR/EPM system.
• Respond to patient inquiries regarding insurance benefits, authorizations, and surgery-related costs.
• Maintain compliance with payer requirements, healthcare regulations, and internal workflows.
• Manage a high volume of work while maintaining accuracy, attention to detail, and excellent customer service.
• Perform other related duties as assigned.

Qualifications & Requirements:

• High School Diploma or equivalent.
• Minimum of 3 years of recent experience in surgical authorization, insurance verification, or healthcare revenue cycle.
• Proficiency in CPT, ICD-10, and HCPCS coding, including modifiers.
• Strong knowledge of insurance authorization processes and payer websites/portals.
• Ability to read and interpret medical records and Explanation of Benefits (EOBs).
• Strong organizational skills with the ability to manage multiple priorities and deadlines.
• Excellent verbal and written communication skills.
• Proficiency with Microsoft Office and electronic medical record (EMR/EPM) systems.
• Ability to work independently and collaboratively in a fast-paced, high-pressure environment.

Work Environment & Physical Expectations:

• Fully Remote
• Monday–Friday, daytime schedule; occasional after-hours meetings may be required.
• Ability to sit for extended periods, move throughout the office as needed, and perform light lifting; manual dexterity required for frequent computer and phone use.

Behavioral Expectations:

• Attention to detail and accuracy.
• Excellent organizational skills.
• Good leadership, interpersonal, and communication skills.