Prior Authorization Specialist

About Our Client

This organization operates in the molecular pathology and healthcare diagnostics industry, focusing on improving patient access to specialized testing through efficient billing and authorization processes. It addresses challenges in the revenue cycle related to prior authorizations, aiming to minimize denials and delays that impact timely patient care.

About the Opportunity

The Prior Authorization Specialist role is responsible for managing and submitting prior authorizations for Category I molecular pathology testing. This position ensures accurate and timely processing of authorizations to support revenue cycle performance and reduce payment delays. It plays a key role in verifying clinical documentation and aligning coding to meet payer requirements.

Responsibilities

• Submit and manage high-volume prior authorizations, approximately 75-100 per day
• Review and interpret medical records, clinical documentation, and lab requisitions
• Submit authorization level appeals as needed
• Perform data entry and verify insurance eligibility and correct insurance assignment
• Update and verify patient demographics for accuracy
• Ensure proper linkage between CPT codes and ICD-10 diagnoses
• Apply payer policies for Commercial, Medicare Advantage, and Medicaid
• Utilize payer portals, automated tools, and internal systems for authorization processing
• Maintain compliance with HIPAA and payer guidelines
• Monitor authorization statuses and complete necessary follow-up actions
• Collaborate with billing teams to resolve authorization discrepancies

Requirements

• 2 to 4 years of experience in prior authorization processing, laboratory billing, or healthcare revenue cycle
• High school diploma required; some college preferred
• Knowledge of CPT coding, preferably molecular, and ICD-10 coding with medical necessity guidelines
• Ability to interpret clinical documentation and testing requests
• Proficiency with Microsoft Excel, Word, Outlook, general office equipment, and ten-key by touch
• Strong analytical, organizational, and communication skills
• Ability to work independently and adapt to high-volume, production-driven environments

Pay Range and Compensation Package

The annualized base salary range for this role is $48,800 to $73,300 and is bonus eligible. Final compensation packages depend on experience, skillset, knowledge, geography, education, business needs, and market demand.

Equal Opportunity Statement

Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.