Medical Prior Authorization for Gastroenterology Specialist

Job Description

Job Description

Job Summary

The Prior Authorization Specialist is responsible for obtaining insurance approvals for gastroenterology services, including office visits, endoscopic procedures (colonoscopy, EGD), imaging studies, medications, infusions, and specialty treatments. The role serves as a liaison between patients, providers, insurance companies, hospitals, and pharmacies to ensure timely authorization and minimize delays in care. 

Essential Duties

• Verify patient insurance eligibility and benefits. 
• Determine whether prior authorization is required for procedures, medications, tests, or referrals. 
• Submit authorization requests through payer portals, fax, or phone. 
• Gather and review clinical documentation, physician notes, CPT codes, and ICD-10 diagnosis codes to support medical necessity. 
• Track pending authorizations and follow up with insurance companies. 
• Communicate approvals, denials, and additional documentation requests to providers, staff, and patients. 
• Document all authorization activity in the electronic medical record (EMR). 
• Coordinate with gastroenterologists, nurses, surgery centers, hospitals, pharmacies, and billing departments. 
• Assist with appeals and peer-to-peer reviews for denied services. 
• Maintain knowledge of payer policies, Medicare, Medicaid, HMO, and PPO requirements. 

Required Skills

• Knowledge of medical terminology, especially gastroenterology procedures. 
• Understanding of CPT, ICD-10, and insurance authorization processes. 
• Experience with EMR systems such as Epic, eClinicalWorks, NextGen, or Athenahealth. 
• Strong attention to detail and organizational skills. 
• Ability to manage multiple authorizations and deadlines simultaneously. 
• Excellent phone, written, and interpersonal communication skills. 

Preferred Qualifications

• High school diploma or GED (required by most employers). 
• Medical Assistant certification, billing/coding certification, or related healthcare experience preferred. 
• 1–3 years of prior authorization, referral coordination, medical billing, or gastroenterology office experience. 
• Familiarity with specialty medications, infusions, and GI procedures. 
• 3 Month probation period 

Common Gastroenterology Procedures You May Authorize

• Colonoscopy 
• Upper Endoscopy (EGD) 
• Capsule Endoscopy 
• ERCP 
• FibroScan 
• CT and MRI imaging 
• Biologic medications for Crohn's Disease and Ulcerative Colitis treatment.