Position Title
Prior Authorization Specialist / Prior Authorization Coordinator
Department
Prior Authorization Department
Job Summary
The Prior Authorization Specialist is responsible for obtaining insurance authorizations and approvals for medical services, treatments, medications, procedures, and equipment. This role works closely with physicians, clinical staff, insurance companies, and patients to ensure timely approvals and accurate documentation while maintaining compliance with payer guidelines and company policies.
Essential Duties and Responsibilities
- ย Submit prior authorization requests to insurance providers for medical services, medications, procedures, and treatmentsย
- ย Verify patient insurance eligibility and benefitsย
- ย Review clinical documentation to ensure authorization requirements are metย
- ย Communicate with physicians, nurses, pharmacies, and other departments regarding authorization status and additional documentation needsย
- ย Follow up with insurance companies on pending, denied, or incomplete authorizationsย
- ย Process authorization renewals and extensions as neededย
- ย Document all authorization activities accurately in the EMR/EHR systemย
- ย Maintain knowledge of insurance payer guidelines, Medicare, Medicaid, and commercial insurance requirementsย
- ย Assist with appeals and denial management when authorizations are deniedย
- ย Ensure all approvals are obtained prior to scheduled services when requiredย
- ย Maintain confidentiality of patient information in compliance with HIPAA regulationsย
- ย Provide excellent customer service to patients and internal staffย
Qualifications
- ย High school diploma or equivalent required; associate degree preferredย
- ย Minimum of 1โ2 years of experience in healthcare, medical billing, insurance verification, or prior authorization preferredย
- ย Knowledge of medical terminology, CPT, ICD-10, and HCPCS coding preferredย
- ย Experience with EMR/EHR systems and insurance portalsย
- ย Strong organizational and multitasking skillsย
- ย Excellent communication and problem-solving abilitiesย
- ย Ability to work independently and in a fast-paced environmentย
- ย Proficiency in Microsoft Office applicationsย
Preferred Experience
- ย Experience in Home Health, Hospice, Specialty Pharmacy, or Medical Office settingsย
- ย Familiarity with Medicare, Medi-Cal/Medicaid, and commercial payer authorization processesย
Physical Requirements
- ย Prolonged periods of sitting and computer workย
- ย Ability to communicate effectively by phone and emailย
- ย Occasional lifting of office materials up to 15 poundsย
Work Environment
- ย Office or healthcare settingย
- ย Standard business hours with occasional overtime depending on authorization volumeย
Skills
- ย Attention to detailย
- ย Time managementย
- ย Insurance verification and authorization processingย
- ย Data entry accuracyย
- ย Customer serviceย
- ย Team collaboration