Guest Eligibility Specialist II

Position Overview

The Guest Eligibility Specialist II manages the front-end eligibility and authorization process with a high degree of independence, efficiency, and technical skill. This role verifies and enters guest information, reviews clinical documentation using HCPCS, CPT, and ICD-10 codes, and initiates, submits, and follows up on authorizations through payer portals or fax.

The position supports workflow improvement efforts, documentation standards, and training initiatives to help ensure guest information is processed accurately, efficiently, and in compliance with organizational and regulatory requirements.

Key Responsibilities

• Perform guest registration and authorization functions across multiple states.
• Reconcile insurance coverage discrepancies and ensure demographic accuracy.
• Validate complex eligibility situations and escalate only when management review is needed.
• Apply knowledge of CPT, HCPCS, and ICD-10 coding when determining authorization needs.
• Manage prior authorizations, reauthorizations, and corrections independently.
• Research denial reasons with payers and recommend corrective actions to maximize reimbursement.
• Support appeals processes by submitting corrected authorizations as needed.
• Maintain detailed tracking of pending and resolved authorizations and payer issues.
• Provide detailed documentation of authorization processes and payer communications.
• Communicate with providers, payers, and internal departments.
• Assist with SOP development, workflow documentation, training, and mentoring.
• Identify payer trends and report findings to Revenue Cycle leadership.