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Prior Authorization Representative Jobs in Michigan

Optimed Pharmacy Inc

Senior Clinical Pharmacist

Kalamazoo, MI · On-site

$111K - $133K/yr

Represent OptiMed with clients, providers, manufacturers, regulators, accrediting organizations, and industry partners. Prior Authorization & Utilization Management * Develop and maintain evidence ...

Sanford Health

Patient Access Representative

Marquette, MI · On-site

$16.75 - $21.25/hr

... prior authorization; track patient/resident visits; health information management on patient ... In all settings, the Patient Access Representative serves as a mentor for new Patient Access ...

Spectrum Health

Patient Services Rep Housecalls

Bridgman, MI · On-site

$16.50 - $21/hr

Job Summary As a Patient Services Representative with Corewell Health, you'll play a vital role in ... Obtains insurance authorizations and/or verifies that prior authorization has been obtained ...

Corewell Health

Patient Services Rep Housecalls

Bridgman, MI · On-site

$16.50 - $21/hr

Job Summary As a Patient Services Representative with Corewell Health, you'll play a vital role in ... Obtains insurance authorizations and/or verifies that prior authorization has been obtained ...

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All JobsPrior Authorization Representative JobsPrior Authorization Representative Jobs in Michigan

Prior Authorization Representative information

See Michigan salary details

$21.4K

$38.5K

$67.1K

How much do prior authorization representative jobs pay per year?

As of Jul 26, 2026, the average yearly pay for prior authorization representative in Michigan is $38,541.00, according to ZipRecruiter salary data. Most workers in this role earn between $32,700.00 and $37,500.00 per year, depending on experience, location, and employer.

What does a prior authorization rep do?

A prior authorization representative reviews and processes requests for medical services or medications that require approval from insurance companies before treatment. They verify patient information, ensure documentation is complete, and communicate with healthcare providers and insurers to obtain necessary approvals, often using specialized software. This role helps ensure that patients receive authorized care while complying with insurance policies.

How much do precertification specialists make?

Precertification specialists, also known as prior authorization representatives, typically earn between $35,000 and $55,000 annually, depending on experience, location, and employer. They often require strong knowledge of insurance policies and medical billing systems, with some roles offering additional certifications to increase earning potential.

What are some common challenges faced by Prior Authorization Representatives, and how can they be managed?

Prior Authorization Representatives often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and dealing with time-sensitive cases. Staying up-to-date with payer requirements and utilizing electronic health record (EHR) systems can help streamline the process. Strong communication and organizational skills are essential for collaborating with healthcare providers and insurance companies to ensure timely approvals and minimize delays for patients.

What is the difference between Prior Authorization Representative vs Medical Billing Specialist?

AspectPrior Authorization RepresentativeMedical Billing Specialist
CredentialsHigh school diploma; certification often preferredHigh school diploma; certification optional
Work EnvironmentHealthcare offices, insurance companiesMedical offices, billing companies
Primary ResponsibilitiesSecuring insurance approvals for proceduresProcessing and submitting medical claims

The Prior Authorization Representative focuses on obtaining insurance approvals before procedures, while the Medical Billing Specialist handles billing and claims processing after services are rendered. Both roles require knowledge of insurance policies and healthcare documentation, but they differ in their primary functions within the healthcare revenue cycle.

What does a Prior Authorization Representative do?

A Prior Authorization Representative is responsible for reviewing and processing requests for prior authorization of medical procedures, medications, or services. They work with healthcare providers, insurance companies, and patients to ensure that the necessary documentation is submitted and meets the insurance requirements for approval. Their role helps facilitate timely access to medical care by verifying coverage and resolving any issues that may delay treatment. Excellent communication and organizational skills are important for this position.

Is prior authorization a stressful job?

Prior Authorization Representatives often work in fast-paced healthcare environments where accuracy and efficiency are important. The job can be stressful due to tight deadlines, high call volumes, and the need to interpret complex insurance policies, but experience and strong organizational skills can help manage the workload.

What are the key skills and qualifications needed to thrive as a Prior Authorization Representative, and why are they important?

To thrive as a Prior Authorization Representative, you need a strong understanding of healthcare insurance processes, medical terminology, and prior authorization guidelines, usually supported by a high school diploma or equivalent. Familiarity with healthcare management software, electronic medical records (EMRs), and payer-specific authorization portals is typically required. Attention to detail, problem-solving abilities, and effective communication are standout soft skills for this role. These competencies are essential to ensure timely and accurate processing of authorizations, minimize claim denials, and support patient access to necessary care.

What jobs pay 4000 a week without a degree?

Prior Authorization Representatives typically do not earn $4,000 weekly; however, some high-paying roles in sales, real estate, or specialized trades can reach that level without a degree. These jobs often require strong communication skills, experience, or certifications and may involve commission or performance-based pay structures.
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Prior Authorization Representative jobs near you
Infographic showing various Prior Authorization Representative job openings in Michigan as of July 2026, with employment types broken down into 1% As Needed, 84% Full Time, 12% Part Time, and 3% Contract. Highlights an 92% Physical, 3% Hybrid, and 5% Remote job distribution, with an average salary of $38,541 per year, or $18.5 per hour.

Senior Clinical Pharmacist

Optimed Pharmacy Inc

Kalamazoo, MI • On-site

$111K - $133K/yr

Full-time

Posted 11 days ago

Job description

Description:

POSITION: Senior Clinical Pharmacist


Who We Are:

OptiMed Health Partners optimizes health outcomes and quality of life through personalized and coordinated care. We have been serving patients for over 30 years with a focus on high-quality care in retail pharmacy, specialty pharmacy, and infusion services. The OptiMed Vision reimagines healthcare solutions to achieve unsurpassed value. Our results-oriented culture fosters learning, providing growth opportunities for our employees and exceptional care for our patients in all 50 states.


The Impact of this Role:

The Senior Clinical Pharmacist serves as a senior clinical leader and medication subject-matter expert, responsible for developing, implementing, and continuously improving clinical strategies that support high-quality, evidence-based, and cost-effective patient care. This role provides oversight of clinical pharmacy programs, utilization management, prior authorization criteria, patient management programs, medication safety, and clinical quality improvement across OptiMed’s pharmacy and PBM business lines. Through collaboration with leadership and operational partners, the Senior Clinical Pharmacist helps improve patient outcomes, promote affordability, maintain compliance, and support organizational growth.


What You’ll be Doing:

Clinical Strategy & Leadership

  • Support and execute OptiMed’s overall clinical strategy.
  • Serve as a senior clinical advisor to executive leadership and internal teams.
  • Develop clinical programs that improve quality, patient outcomes, and total cost of care.
  • Monitor emerging clinical evidence, treatment guidelines, therapeutic developments, and market trends.
  • Provide leadership in formulary management, specialty pharmacy, specialty infusion, value-based care, and emerging therapies.
  • Represent OptiMed with clients, providers, manufacturers, regulators, accrediting organizations, and industry partners.

Prior Authorization & Utilization Management

  • Develop and maintain evidence-based prior authorization criteria across applicable therapeutic classes.
  • Ensure clinical criteria align with current guidelines, FDA labeling, specialty-society recommendations, and payor objectives.
  • Evaluate new medications, biosimilars, and specialty therapies for appropriate utilization-management strategies.
  • Recommend changes to step therapy, quantity limits, site-of-care optimization, and specialty pharmacy protocols.
  • Monitor approval trends, appeals, provider feedback, and clinical outcomes to improve program effectiveness.
  • Participate in complex prior authorization appeals and peer-to-peer reviews.

Patient Management & Clinical Pharmacy Services

  • Develop patient management programs and monitoring protocols for specialty medications, chronic conditions, and high-risk therapies.
  • Create clinical interventions that improve medication adherence, persistence, safety, and therapeutic outcomes.
  • Develop clinical pathways for oncology, autoimmune and inflammatory conditions, rare diseases, obesity, and other relevant populations.
  • Establish standards for patient education, clinical outreach, and ongoing therapy management.
  • Provide clinical consultation to providers, clients, pharmacists, and care-management teams.
  • Support formulary development and evaluate medications for effectiveness, safety, appropriateness, and cost optimization.

Clinical Quality, Compliance & Outcomes

  • Partner with Compliance and Quality Management to ensure alignment with URAC, ACHC, state Boards of Pharmacy, and other applicable requirements.
  • Develop policies and procedures supporting accreditation and clinical quality standards.
  • Monitor clinical quality indicators and implement quality-improvement initiatives.
  • Maintain medication-safety and pharmacovigilance processes.
  • Support audit readiness and regulatory inspections.
  • Use clinical analytics to evaluate program performance, medication utilization, adherence, outcomes, and total cost of care.
  • Establish key performance indicators and identify opportunities for program improvement.

Leadership & Team Development

  • Mentor and develop pharmacists, pharmacy residents, and clinical staff.
  • Promote clinical excellence, innovation, accountability, and continuous improvement.
  • Strengthen interdisciplinary collaboration across clinical, operational, and administrative teams.
  • Lead strategic clinical initiatives and enterprise-wide projects.

Who You’ll be Working With:

The Senior Clinical Pharmacist reports to the Director of Pharmacy, with support from the Chief Medical Officer. This role works closely with executive leadership, pharmacy operations, PBM teams, Quality Management, Compliance, pharmacists, care-management teams, and other clinical and operational partners. The Senior Clinical Pharmacist also engages with providers, clients, manufacturers, payors, regulatory agencies, accrediting organizations, and industry partners.

Skills and Experience You’ll Bring to the Table:

  • Doctor of Pharmacy degree from an accredited program
  • Active Michigan pharmacist license in good standing
  • Additional state pharmacist licenses preferred
  • Minimum of seven years of progressive clinical pharmacy experience
  • Minimum of three years of leadership experience
  • Experience in PBM, managed care, specialty pharmacy, health plan pharmacy, infusion pharmacy, or clinical program development
  • Experience developing prior authorization criteria and utilization-management or patient-management programs
  • Experience presenting clinical recommendations to executive leadership and clinical committees
  • Relevant board certification, such as BCPS, BCACP, BCOP,BCIDP, BC-ADM, CSP, or another applicable credential preferred
  • Knowledge of evidence-based medicine, formulary management, specialty pharmacy, pharmacoeconomics, medication safety, clinical analytics, regulatory compliance, and value-based care

Competencies You’ll Bring to the Table:

  • Strategic leadership and clinical excellence
  • Critical thinking and sound decision-making
  • Executive presence and professional communication
  • Collaborative and interdisciplinary leadership
  • Patient-centered care and financial stewardship
  • Quality improvement and change management
  • Regulatory expertise and accountability

Work Environment:

The Senior Clinical Pharmacist works in a professional pharmacy and office environment and regularly uses computers, telephones, and standard office equipment. This role requires frequent in-person and virtual collaboration and may involve occasional travel. Reasonable accommodations may be made in accordance with applicable laws.


OptiMed Health Partners provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Requirements: