Prior Authorization Specialist-1.0 FTE

Job Summary:

The Prior Authorization Specialist is responsible for coordinating and securing prior authorization for medical procedures, surgeries, medications, therapies, and services as required by insurance payers. This role ensures compliance with insurance guidelines and minimizes delays in patient care by managing the authorization process efficiently and accurately. This position requires a strong understanding of policies, medical terminology, and the ability to handle detailed tasks in a fast-paced environment.

Hours: Monday-Friday, 8:00AM-4:30PM.

Key Responsibilities:

• Review and process prior authorizations request for medical services, procedures, surgeries, medications, and/or therapies.
• Utilize payer websites to check insurance eligibility, submit prior authorization requests, and check prior authorization status.
• Communicate with insurance payers as needed to determine plan requirements and obtain prior authorization approval or denial.
• Clarify any missing, incomplete or erroneous information in the authorization request and provide guidance to the medical team.
• Maintain accurate and up-to-date records of all prior authorization requests, approvals, denials, and related communications.
• Review and analyze denied prior authorization requests and collaborate with the medical team to appeal the decision.
• Ensure compliance with HIPAA and other relevant regulations to protect patient information and privacy.

Skills and Qualifications:

Education: High school diploma or equivalent required; Associate’s or Bachelor's degree in healthcare administration or related field preferred

Experience:

• Previous experience in healthcare administration, medical billing, or insurance verification is highly preferred.
• Experience working with insurance payers and understanding insurance terminology is a plus.
• Knowledge of medical terminology, coding (CPT, ICD-10, HCPCS) is advantageous.
• Proficiency with electronic health record systems (EHR) and insurance payer portals.

Competencies:

1. Strong attention to details and organizational skills.
2. Excellent verbal and written communication skills.
3. Ability to work independently and manage multiple tasks efficiently.
4. Strong problem solving skills, particularly when dealing with denied authorizations.
5. Knowledge of HIPAA regulations and confidentiality practices.