Guest Eligibility Specialist II Louisiana and North Carolina

The Guest Eligibility Specialist II manages the front-end eligibility and authorization process across multiple states with greater independence and technical skill, verifying and entering guest information, reviewing clinical documentation using CPT, HCPCS, and ICD-10 codes, and initiating, submitting, and following up on authorizations through payer portals or fax. Applies advanced coding knowledge to determine authorization needs, ensures compliance with payer requirements and regulatory standards, documents payer communications, and contributes to SOPs and workflow improvements. Responsibilities include registration and eligibility verification, reconciliation of coverage discrepancies, resolving complex eligibility scenarios, processing prior authorizations and reauthorizations, supporting appeals, and mentoring staff while maintaining accurate tracking of pending and resolved authorizations. The role emphasizes professional communication with providers, payers, and internal teams, and requires familiarity with CMS guidelines, contracted insurance guidelines, coding policies, and HIPAA confidentiality, with a focus on maximizing reimbursement and reducing denials.