Prior Authorization Specialist

Job Description

Job Description

We are currently seeking an experienced, highly organized, and detail-oriented Prior Authorization Specialist to join our team at our Millville location.  This position requires a full-time, on-site presence.

The Prior Authorization Specialist is responsible for managing the prior authorization process for diagnostic testing, medical procedures, treatments, office visits, and other services requiring insurance approval.  This role works closely with providers, clinical staff, scheduling, billing, insurance companies, and patients to ensure necessary approvals are obtained accurately and efficiently and to help prevent delays in patient care.

The ideal candidate will have strong prior authorization and insurance verification experience, be comfortable navigating multiple payer portals, and have the ability to independently manage authorization requests from initial submission through approval, denial, or appeal. We’re looking for someone who understands that timely and accurate prior authorizations directly impact a patient’s ability to receive care.  The ideal candidate is organized, persistent, comfortable navigating complex insurance requirements, and takes ownership of each authorization from start to finish.  You should be comfortable managing multiple requests at once, following up when answers aren’t readily available, communicating clearly with providers and insurance companies, and making sure nothing falls through the cracks.

Responsibilities

Prior Authorization Management

• Initiate, track, and complete prior authorization requests for diagnostic testing, procedures, treatments, office visits, and other medical services.
• Review patient medical histories, physician orders, and supporting clinical documentation to determine authorization requirements.
• Gather and submit required clinical information and documentation to insurance carriers.
• Navigate insurance payer portals and communicate directly with insurance companies regarding authorization requirements and status.
• Monitor pending authorization requests and proactively follow up to help prevent delays in scheduling and patient care.

Insurance Verification & Eligibility

• Verify patient insurance coverage, eligibility, and benefits prior to submitting authorization requests.
• Review applicable coverage requirements and confirm information needed to obtain approval.
• Identify potential insurance or authorization issues and work proactively to resolve them.

Communication & Coordination

• Work closely with physicians, clinical staff, and schedulers to obtain necessary clinical documentation and additional information.
• Communicate authorization status, approvals, denials, and outstanding requirements to the appropriate providers, scheduling, and billing teams.
• Notify patients of authorization outcomes or additional requirements when appropriate.
• Monitor scheduling and proactively address authorization-related issues that could delay patient care.

Denials & Appeals

• Review authorization denials to determine the reason for denial and whether an appeal or additional documentation may be appropriate.
• Prepare and submit appeals with supporting clinical documentation when necessary.
• Track appeal submissions, follow-up activity, and outcomes.

Documentation & Administrative Support

• Maintain accurate and detailed records of authorization requests, approvals, denials, appeals, and insurance communications within the electronic health record (EHR).
• Maintain patient confidentiality and comply with HIPAA and organizational policies.
• Assist with additional clerical and administrative responsibilities as needed to support efficient department operations.

Qualifications

• Minimum of 5 years of experience with testing and/or procedure prior authorizations and insurance verification preferred.
• Minimum of 2 years of direct procedure prior authorization experience required.
• Strong working knowledge of medical terminology, ICD-10 and CPT codes.
• Strong understanding of insurance guidelines and prior authorization processes.
• Experience navigating multiple insurance payer portals and requirements.
• Proficiency with electronic health records (EHR), practice management systems, and other healthcare software.
• Strong attention to detail with a commitment to accuracy.
• Excellent organizational and time-management skills with the ability to prioritize multiple authorization requests and follow-up activities.
• Strong written and verbal communication skills.
• Ability to work independently with minimal supervision while effectively collaborating with providers, insurance carriers, patients, and internal teams.
• Strong initiative and problem-solving skills with the ability to proactively identify and resolve authorization issues.

Benefits

Our comprehensive benefits package includes:

• Medical insurance
• Dental insurance
• Vision insurance
• 401(k) with company matching
• Paid time off
• Life insurance
• Disability insurance
• Long-term disability coverage
• Critical illness coverage

Position Details

Job Type: Full-Time
Expected Hours: 40 hours per week
Schedule: Monday–Friday, 9:00 AM–5:00 PM
Work Location: On-site at our Millville, NJ location
Pay: Up to $22.00 per hour