Clinical Authorization Specialist (Utilization Review)

Key Responsibilities

• Review and process prior authorization requests for medical procedures, diagnostic testing, medications, therapies, and specialty services.
• Evaluate clinical documentation to determine medical necessity using payer guidelines, evidence-based criteria, and insurance policies.
• Perform prospective, concurrent, and retrospective utilization reviews.
• Communicate with physicians, nurses, case managers, and insurance representatives to obtain required clinical documentation.
• Submit authorization requests and monitor status through payer portals and electronic health record (EHR/EMR) systems.
• Track authorization approvals, denials, appeals, and expiration dates to ensure continuity of care.
• Identify incomplete or missing documentation and coordinate with providers to obtain necessary information.
• Maintain accurate records of all authorization activities, communications, and determinations.
• Stay current on payer policies, CMS regulations, and utilization management best practices.
• Affiliate with appeals and peer-to-peer review coordination when necessary.

Required Qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree in a healthcare-related field preferred.
• Minimum of 2 years of experience in prior authorization, utilization review, medical insurance, case management, including admissions.
• Strong understanding of commercial insurance, Medicare, Medicaid, and managed care plans.
• Experience working with electronic medical records (EMR/EHR) and payer authorization portals.
• Excellent organizational, analytical, and problem-solving skills.
• Strong verbal and written communication abilities.
• Ability to prioritize multiple tasks in a fast-paced healthcare environment.

Benefits

• Set schedule: Monday- Friday 9 am- 5pm
• Full benefit package available
• Matching 401K
• Time off accrued each payroll
• Free employee meals