Prior Authorization Specialist

A prior authorization specialist is an individual who is highly skilled in ensuring that patients receive the medication and/or diagnostic services that requires pre-authorization from insurance carriers. These individuals address and rectify rejected claims and conduct necessary third party authorization requests.

1. Good Judgment
2. Communication/Customer Service/Teamwork
3. Passion
4. Honesty
5. Responsibility
6. Job-Specific Skill Set

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

• Follow prior authorization work flow policies and procedures
• Collaborate with other departments to assist in obtaining prior authorizations.
• Review accuracy and completeness of information requested and ensure that all supporting documents are present
• Receive requests for prior authorizations and ensure that they are properly and closely monitored.
• Process referrals and submit clinical supporting documentation to insurance carriers to expedite prior authorization processes
• Manage correspondence with insurance companies, clinicians and patients as required
• Document all prior authorization information including approval dates, prior authorization number in hospital system
• Proactively work on prior authorizations that are timely
• Secure patients’ demographics and medical information by ensuring that all procedures are in sync with HIPAA compliance and regulation
• Advise providers and their clinical staff when issues arise relating to obtaining prior authorization
• Stay informed and research information regarding insurance criteria changes/updates for prior authorization

• High school diploma or GED.
• 2+ years of related experience; prior- authorization experience highly desired
• Knowledge of medical terminology - Understanding of insurance requirements for prior authorization
• Experience in Radiology / Pharmacy / Laboratory Prior Authorizations
• Understanding of CPT codes and vast knowledge of insurance required
• Knowledge of eCW or other electronic health record preferred
• Knowledge of Commercial Payors, Medicare & Medicaid desired
• Excellent verbal, written, organizational and customer service skills
• Ability to work independently, meet deadlines and be flexible
• Ability to perform tasks accurately and efficiently when entering data electronically
• Proficient typing/keyboarding skills
• Basic knowledge of Microsoft Office, Excel and Outlook
• Physical Demands: Must be able to sit for long periods of time.  Must be able to lift 25-50 pounds.  Must be able to ambulate for extended periods of time.
• Embraces the team concept; encourages and models healthy, productive team behavior
• Bilingual (English/Spanish) is a plus, but not required - applicants who may serve in a translating capacity will be required to take a language assessment