Prior Authorization Representative Express Scripts Jobs

Position Title: Prior Authorization Specialist

Supervisor: Prior Authorization Manager

FLSA Status: Non-Exempt

Mission:

To provide our patients and community the most innovative and breakthrough treatment options to improve overall health and wellness.

Values:

Innovation

Integrity

Patient Experience

Teamwork

Job Summary:

Under the direction of the Prior Authorization Manager, the Prior Authorization Specialist supports the business office by reviewing patient insurance information to determine whether treatments, procedures, or medications require prior authorization. This role is responsible for preparing and submitting authorization requests to insurance companies, ensuring all required documentation is complete and accurate.

Key responsibilities of this role include, but are not limited to:

• Manage and process prior authorizations for Medicare, Commercial, Medicaid, and Workers’ Compensation cases, including injections, procedures, and other services requiring approval.
• Review and verify patient insurance coverage and coordinate with patients regarding pre-procedure requirements.
• Maintain up-to-date knowledge of insurance prior authorization requirements, policies, and guidelines.
• Communicate effectively with insurance companies, physician offices, external vendors, and patients.
• Serve as a resource for providers in determining authorization requirements for patient care.
• Manage authorization denials and coordinate the appeals process as needed.
• Complete and maintain accurate prior authorization documentation and records.
• Support prior authorization-related projects and track performance metrics as required.
• Cross-train and assist with additional duties as assigned.

Supervisory Responsibility:

• This position has no supervisory responsibilities.

Qualifications:

• High School Diploma or GED required. Associate’s degree preferred.
• Minimum of one (1) year of prior authorization experience in a healthcare setting preferred.
• Familiarity with medical terminology, including CPT/HCPCS codes, ICD-10 codes, and procedures preferred.
• Experience with NextGen or similar electronic health record (EHR) systems preferred.

Skills & Abilities:

• Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment.
• Excellent verbal and written communication skills.
• Solid understanding of insurance coverage and eligibility processes.
• Strong problem-solving and critical-thinking abilities.
• Proficiency in computer systems and standard business software.
• Self-motivated, reliable, and consistent work ethic.
• Ability to multitask and work both independently and collaboratively within a team.
• Professional demeanor and ability to represent the organization effectively.
• Ability to follow supervisor directives and adhere to company policies and procedures.
• Commitment to maintaining confidentiality and compliance with HIPAA regulations.

Work Environment:

While performing the duties of this job, the employee regularly works in an office setting. This is not a remote role!

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

While performing the duties of this job, the employee is occasionally required to walk; sit; use hands to grasp or handle objects, tools, or controls; reach with hands and arms; stoop, kneel, or crouch; talk or hear. The employee must be able to sit for 90% of the day and occasionally lift or move up to 10 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Compensation & Work Schedule:

• Full-time: 40 hours/week.
• Non-Exempt.
• Day Shift: Monday - Friday, 8:30AM – 5:00PM (*hours will vary during training period).
• No evenings or weekends.
• A competitive benefits package including medical, dental, vision, life, and disability insurance, 401(k), PTO time, paid holidays, and HSA plan is offered.