Prior Authorization Specialist

About the role

The Prior Authorization Specialist is responsible for coordinating and obtaining insurance authorizations and pre-certifications for patient visits, diagnostic services, procedures, and other covered healthcare services across multiple clinical specialties. This position works collaboratively with providers, clinical staff, insurance payers, and patients to ensure authorization requirements are met prior to services being rendered.

Responsibilities

• Reviews scheduled services, referrals, and provider orders to determine insurance authorization requirements.
• Obtains and manages prior authorizations and pre-certifications for patient visits, diagnostic services, procedures, and other covered healthcare services across multiple clinical specialties.
• Utilizes multiple commercial, Medicare, Medicaid, and managed care payer portals to submit, monitor, and maintain authorization requests.
• Reviews clinical documentation for completeness and medical necessity to support authorization requests and collaborates with clinical staff to obtain additional information as needed.
• Tracks authorization requests from submission through determination, documenting authorization status, reference numbers, effective dates, and applicable service limitations in the electronic health record and other designated systems.
• Communicates authorization approvals, denials, pending requests, and payer requirements to providers, clinical staff, scheduling personnel, and patients, as appropriate.
• Collaborates with clinical staff to coordinate additional documentation, reconsiderations, appeals, or peer-to-peer review requests when required by the payer.
• Maintains current knowledge of payer-specific authorization requirements, coverage guidelines, and regulatory changes.
• Identifies opportunities to improve authorization workflows and communicates trends or concerns to the HIM Supervisor.
• Ensures compliance with HIPAA, organizational policies, payer requirements, and applicable federal and state regulations.

Requirements

• Minimum of two (2) years of experience in prior authorization, revenue cycle management, referral management, or health information management.
• Experience working with commercial, Medicare, Medicaid, and managed care insurance plans.
• Experience working with electronic health records (EHR) and multiple payer or insurance portals.
• Basic knowledge of medical terminology, insurance verification, and prior authorization processes.
• Proficient computer skills, including Microsoft Office and the ability to learn new software applications.
• High school diploma or equivalent required.
• Ability to speak Spanish desirable.
• Experience in a multi-specialty healthcare practice or Federally Qualified Health Center (FQHC).
• Experience using NextGen EHR.