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Prior Authorization Jobs in Riverside, CA (NOW HIRING)

LWC, Inc.

Application Support

Santa Ana, CA

To provide production support for PAS - Prior Authorization System application which is a critical business application as part of the PAS SSMO team. This includes incident management, availability ...

LWC, Inc.

Application Support

Santa Ana, CA · On-site

Company Description Development/Application Support Santa Ana CA 6 month Contract to hire (1) Critical business need for the role: • To provide production support for PAS - Prior Authorization ...

Riverside Digestive and Liver Health Clinic

Be Seen First

Gastroenterology Endoscopy Procedure Referral Coordinator & Scheduler

Riverside, CA · On-site

$19 - $22/hr

Verify insurance eligibility and obtain prior authorizations/pre-certifications as required * Communicate preparation instructions and appointment details to patients * Maintain accurate patient ...

New

Riverside Digestive and Liver Health Clinic

Be Seen First

Gastroenterology Endoscopy Procedure Referral Coordinator & Scheduler

Riverside, CA · On-site

$19 - $22/hr

Verify insurance eligibility and obtain prior authorizations/pre-certifications as required * Communicate preparation instructions and appointment details to patients * Maintain accurate patient ...

New

Medix

Pharmacy Technician

Orange, CA · On-site

$20 - $26/hr

Resolve prescription-related issues, including prior authorization requirements, third-party rejections, and pharmacy claim issues * Collaborate with retail and mail-order pharmacies to troubleshoot ...

Oso Home Care

Intake Coordinator - Full-Time

Irvine, CA · On-site

$26 - $33/hr

Verify insurance coverage and obtain prior authorizations as needed. * Schedule and coordinate home infusion services, ensuring timely delivery of medications and supplies. * Maintain accurate and up ...

New

Oso Home Care

Intake Coordinator - Full-Time

Irvine, CA · On-site

$26 - $33/hr

Verify insurance coverage and obtain prior authorizations as needed. * Schedule and coordinate home infusion services, ensuring timely delivery of medications and supplies. * Maintain accurate and up ...

New

Healthcare Support Staffing

Pharmacy Technician

Irvine, CA

$18.75 - $22.75/hr

Take incoming requests for prior authorizations, for formulary and non-formulary medications, while ensuring a high level of customer service and maximizing productivity * Answer prior authorization ...

Astiva Health

Member Services Representative

Orange, CA

$24 - $29/hr

Fully understand all aspects of Medicare Advantage including but not limited to benefits, prior authorization, referrals, claims, enrollment, eligibility, appeals & grievances, providers networks and ...

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All JobsPrior Authorization JobsPrior Authorization Jobs in Riverside, CA

Prior Authorization information

See Riverside, CA salary details

$14

$21

$33

How much do prior authorization jobs pay per hour?

As of Jun 12, 2026, the average hourly pay for prior authorization in Riverside, CA is $21.80, according to ZipRecruiter salary data. Most workers in this role earn between $18.08 and $24.09 per hour, depending on experience, location, and employer.

How much do precertification specialists make?

Precertification specialists typically earn a median annual salary between $40,000 and $55,000, depending on experience, location, and employer. They often require knowledge of insurance policies and medical billing software, with some roles offering additional certifications to increase earning potential.

What Is Prior Authorization?

Prior authorization is a check done by insurance companies and other third-party payers to determine whether or not they should pay for a medical procedure or specific medication. Factors that can trigger prior authorization requests include things like age, the availability of alternative medicines, or the need to check for drug interactions. If they reject the prior authorization, payers often require doctors to attempt the insurance company's preferred procedure and verify unsuccessful results before accepting an alternative treatment plan. Pre-authorization requests can take up to 30 days, though insurance companies and healthcare providers are continuing to work on ways to cut this time down.

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

To thrive as a Prior Authorization Specialist, you need strong knowledge of medical terminology, insurance processes, and healthcare regulations, typically supported by a high school diploma or associate degree in a healthcare-related field. Familiarity with electronic medical records (EMR) systems, insurance portals, and authorization management software is essential. Attention to detail, effective communication, and problem-solving abilities help you navigate complex cases and collaborate with providers and payers. These skills ensure accurate and timely processing of authorizations, minimizing delays in patient care and reducing administrative errors.

What are some common challenges faced by Prior Authorization specialists, and how can applicants prepare for them?

Prior Authorization specialists often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and communicating effectively with both healthcare providers and insurance representatives. To prepare for these challenges, applicants should develop strong organizational skills, attention to detail, and a good understanding of medical terminology and insurance guidelines. Familiarity with electronic health records (EHR) systems and the ability to multitask in a fast-paced environment are also valuable assets in this role.

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

AspectPrior AuthorizationMedical Billing Specialist
CredentialsTypically requires knowledge of insurance policies, healthcare regulations, and sometimes certifications like NCQA or AHIPRequires knowledge of coding, billing procedures, and often certifications like CPC or CCS
Work EnvironmentHealthcare provider offices, insurance companies, or hospitalsMedical offices, billing companies, or healthcare facilities
Employer & Industry UsageUsed by healthcare providers and insurers to approve treatments or proceduresUsed by healthcare providers and billing companies to process claims and payments

While both roles are essential in healthcare administration, Prior Authorization focuses on obtaining approval for treatments, whereas Medical Billing Specialists handle the financial aspects of claims processing. Understanding their differences helps clarify their distinct responsibilities within the healthcare system.

What does a prior authorization job do?

A prior authorization specialist reviews and processes requests for approval of medical procedures, medications, or treatments from insurance companies. They verify patient information, ensure documentation is complete, and communicate with healthcare providers and insurers to obtain necessary approvals, often using electronic health record systems. This role helps ensure that necessary care is authorized while complying with insurance policies.

What job makes $10,000 a month without a degree?

High-paying jobs that can reach $10,000 a month without a degree include roles like sales managers, real estate brokers, or certain skilled trades such as electricians or plumbers, especially with experience and certifications. These positions often require strong skills, industry knowledge, and sometimes licensing, but not necessarily a college degree.

What is prior authorization in healthcare?

Prior authorization is a process used by health insurance companies to determine if they will cover a prescribed procedure, service, or medication. Before the provider delivers the service, they must receive approval from the insurer. This process helps control costs and ensures that the service or medication is medically necessary. It often involves submitting documentation and waiting for a decision, which can sometimes delay patient care. Patients and providers should check with insurance companies to understand which services require prior authorization.

What career paths follow prior authorization?

Careers following prior authorization include roles such as medical billers, claims processors, healthcare administrators, and utilization review specialists. These positions often require knowledge of insurance policies, medical coding, and healthcare regulations, and may involve working in insurance companies, healthcare providers, or pharmacy benefit management companies.
More about Prior Authorization jobs
What are the most commonly searched types of Prior Authorization jobs in Riverside, CA? The most popular types of Prior Authorization jobs in Riverside, CA are:
What are popular job titles related to Prior Authorization jobs in Riverside, CA? For Prior Authorization jobs in Riverside, CA, the most frequently searched job titles are:
What job categories do people searching Prior Authorization jobs in Riverside, CA look for? The top searched job categories for Prior Authorization jobs in Riverside, CA are:
What cities near Riverside, CA are hiring for Prior Authorization jobs? Cities near Riverside, CA with the most Prior Authorization job openings:
Prior Authorization jobs near you

Billing and Credentialing Specialist

Clinivoy LLC

Irvine, CA

$23 - $28/hr

Full-time

Posted 18 days ago

Job description

Profile Summary:

The Billing & Credentialing Specialist is responsible for managing the full revenue cycle for infusion services, including benefits investigation, verification, accurate claim submission, denial resolution, and AR follow-up. This role handles complex buy-and-bill infusion billing, including J-codes, S-codes, NDC crosswalks, biologics, and time-based infusion services. 

Additionally, the specialist manages provider credentialing and enrollment with Medicare, Medi-Cal, and commercial payers, ensuring compliance and timely activation. The position supports patients, providers, and internal departments to optimize reimbursement and maintain continuity of care.

Key Accountabilities: 

Medical Benefits Billing & Revenue Cycle Management 

  1. Verify medical benefits for infusion services, including specialty biologics, IVIG, and injectable therapies. 

  1. Complete detailed benefit investigation (BI) for medical benefits, deductible, OOP, copay, and coverage limitations. 

  1. Process, correct, and submit claims using CMS-1500 and UB-04 forms for facility and professional billing. 

  1. Apply proper coding for infusion services including: 

  • J-codes / S-codes 

  • NDC conversions & crosswalks 

  • Infusion CPT codes (96365-96379, 96401-96417) 

  • Modifier accuracy (JW, JG, 59, 25, etc.) 

  1. Manage buy-and-bill billing including ASP pricing, wastage documentation, and payer-specific requirements. 

  1. Monitor claim status and process secondary or tertiary claims as required. 

  1. Perform comprehensive AR collections, including tracking outstanding balances and resolving unpaid or underpaid claims. 

  1. Research and resolve claim errors, coding issues, and payer-specific infusion policies. 

  1. Manage prior authorization follow-up with the PA team and ensure claims are billed compliant with authorization terms. 

  1. Communicate with payers to resolve rejections, eligibility discrepancies, and coverage issues. 

Denials, Appeals & Reconsiderations 

  1. Review, analyze, and resolve claim denials related to medical necessity, coding, benefit coverage, or documentation. 

  1. Prepare and submit appeal packets including clinical justifications, medical records, infusion notes, and prior authorization details. 

  1. Draft high-quality appeal letters based on denial category and payer requirements. 

  1. Track appeal turnaround times and follow up with payers until resolution. 

  1. Coordinate with prescribers to obtain clinical notes, labs, and additional documents required for approvals or appeals. 

Provider Credentialing & Payer Enrollments 

  1. Complete credentialing and enrollment for providers with Medicare, Medi-Cal, and commercial insurance plans. 

  1. Maintain and update CAQH, NPPES, PECOS, and payer portal information. 

  1. Initiate and manage re-credentialing processes and track expiring documents. 

  1. Maintain an organized, compliant credentialing database. 

  1. Communicate with insurers and internal teams to ensure timely activation of provider billing privileges.

Division team/specific Accountabilities:  

  1. Communicate with patients to gather information required for benefits verification, billing setup, financial counseling, and to ensure accurate processing of infusion orders and authorizations. Build clear, supportive communication that promotes trust and patient loyalty. 

  1. Investigate and verify medical benefits for infusion and specialty biologic services, including deductible, co-pay, out-of-pocket costs, prior authorization requirements, site-of-care restrictions, step therapy, and medical policy guidelines. 

  1. Coordinate with manufacturer financial assistance programs, copay foundations, and internal support teams to help eligible patients obtain financial support, copay cards, or patient-assistance funding when appropriate. 

  1. Work closely with the Prior Authorization team by providing all required clinical and documentation updates, ensuring timely submission, tracking authorization progress, and maintaining consistent communication with the patient and provider. 

  1. Facilitate denial and appeal processes by requesting denial documentation, gathering clinical records, and preparing appeal packets. Compose appeal letters based on denial reason, medical necessity, and the patient's clinical condition. 

  1. Conduct regular status checks with insurance companies on pending authorizations, appeals, and claim adjudications. Obtain approval information, document outcomes, and update copay or financial assistance statuses when required. 

  1. Identify, track, and escalate service-delaying issues related to prior authorizations, benefit determinations, clinical documentation, or financial assistance gaps to ensure uninterrupted patient therapy and timely infusion scheduling. 

  1. Build and maintain effective working relationships with prescriber offices, referral partners, and clinical staff treating assigned disease states. Provide ongoing updates regarding case status, authorizations, and payer requirements. 

  1. Complete all required assessments or checklists mandated by manufacturer programs, payer requirements, or internal workflow processes to ensure compliance with program standards. 

  1. Review and respond to notifications of patients who require financial assistance, providing them with available program options, community resources, and support to help minimize out-of-pocket burden. 

  1. Assist patients with submitting financial assistance applications, including obtaining consent forms, uploading documentation, completing electronic applications, and following up with financial assistance programs to prevent therapy interruptions. 

  1. Maintain timely updates on pending or unfilled infusion orders, keeping prescription and authorization statuses current in the system at least every 48 hours or per department protocol. 

  1. Ensure that all activities comply with organizational standards, payer guidelines, manufacturer program requirements, and HIPAA. Deliver service in a manner that meets the highest standards of quality, accuracy, and patient care. 

Experience:

  • A minimum of 2 years of prior experience in a medical records department or like setting preferred.  

  • Prior experience with an Infusion clinic. (preferred) 

  • Dealing with third party billers. (preferred)

Behavioral Competencies:

  • Excellent verbal and written communication skills.   

  • Excellent interpersonal, negotiation, and conflict resolution skills.  

  • Excellent organizational skills and attention to detail.  

  • Strong analytical and problem-solving skills.  

  • Ability to prioritize tasks and to delegate them when appropriate.  

  • Ability to act with integrity, professionalism, and confidentiality.

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