Prior Authorization Specialist

This position is responsible for managing prior authorizations, coordinating between providers and payors, verifying clinical documentation, resolving denials, and supporting efficient, compliant access to treatments, medications, and services.

Job Functions

1. Contacts insurance companies on behalf of patients and clinic to obtain prior authorizations for prescriptions, tests and procedures
2. Serves as a patient advocate and functions as a liaison between the patient, provider and payor for prior authorization
3. Provides information to support the medical necessity of patient medications, treatments and testing
4. Communicates with physicians and their team members to obtain necessary information as well as to inform them of any special requirements by particular insurance plans
5. Researches additional or alternative resources for non-covered services
6. Monitors incoming orders and gathers necessary documentation to ensure pre-certification, authorization, and referral requirements are met prior to the delivery of outpatient and ancillary services
7. Works with insurance companies and staff to obtain initial and ongoing authorizations for patients in advance of services
8. Reviews accuracy and completeness of information requested to ensure that all supporting documents are present
9. Researches, corrects, and resubmits rejected/denied insurance authorizations or peer to peer authorizations
10. Conducts clinically informed review of provider orders, documentation, and medical records to determine medical necessity based on payer guidelines and evidence-based criteria
11. Identifies missing, insufficient, or inconsistent clinical information and proactively obtains clarifications from providers
12. Reviews denial trends and recommends clinical-focused process improvements to reduce avoidable denials
13. Performs other duties as assigned.

Minimum Qualifications

• CMA or LPN
• 1 year of experience

Knowledge/Skills and Abilities

* Ability to meet and maintain the necessary background checks as aligned with position functions.

* Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above.

* Knowledge of Payer requirements and expectations regarding prior authorization

* Knowledge of pharmacy, pharmaceuticals, or healthcare business

* Familiarity with CPT/HCPCS and ICD-10

* Ability to proficiently analyze and interpret clinical criteria

* Works effectively across organization and fosters teamwork

* Demonstrated excellent customer service and communication skills - verbal, written, and listening

* Demonstrated knowledge of medical terminology

* Must demonstrate ability to work independently with analytical, problem-solving and decision- making