Medication Prior Authorization Specialist

Medication Prior Authorization Specialist

The specialist prepares and submits required documentation and follows up with insurance providers to secure approvals or resolve denials. They collaborate closely with the clinical team to obtain supporting clinical information, including chart notes and medical necessity documentation. Additionally, this role monitors authorization statuses, communicates updates to clinical staff and patients, and assists in identifying alternative medication or coverage options when necessary.

Demonstrates competency in the following areas:

• Supports a team-oriented environment and contributes to achieving departmental and organizational goals. Builds positive working relationships and supports Quality Improvement, Risk Management, and Compliance initiatives.
• Maintains strict confidentiality of patient information in accordance with HMC policies and procedures.
• Ensures all required medical documentation is accurate and complete prior to submission of authorization requests.
• Effectively communicates with payers via electronic systems, telephone, and fax.
• Completes payer notifications within 24 business hours of service to ensure compliance with managed care requirements.
• Proactively manages and follows all outstanding authorization requests to promote timely processing and clean claim submission.
• Collaborates with billing and clinical departments to meet organizational performance goals.
• Regularly follows up on pending authorizations to determine status and address any additional requirements.
• Communicates authorization approvals and denials promptly to appropriate staff.
• Reviews and resolves discrepancies, errors, and omissions related to authorization denials and submits appeals when appropriate.
• Works cross-functionally with departments to obtain necessary pre-authorizations.
• Identifies and reports trends related to incomplete or inaccurate information.
• Stays current on payer policies, procedures, and regulatory changes.
• Maintains efficient turnaround times to ensure timely processing of authorizations.

High school diploma or equivalent required; prior clerical experience preferred. Minimum of one (1) year of experience in a pharmacy, clinic, or hospital setting.

Ability to communicate effectively in English, both verbally and in writing. Strong interpersonal and communication skills.

• Basic knowledge of medications, insurance plans, prior authorization processes, and terminology
• Ability to manage interruptions, variable workloads, and meet critical deadlines in a fast-paced environment
• Strong customer service focus in interactions with patients, staff, and providers
• Demonstrates reliability through consistent attendance and flexibility to meet departmental needs
• Shows initiative, creativity, and willingness to improve processes and workflows
• Builds positive working relationships and is open to feedback and collaboration
• Strong organizational skills with attention to detail and ability to prioritize tasks effectively
• Communicates clearly and professionally:
• Expresses ideas appropriately using effective communication methods
• Interacts with coworkers and patients openly and respectfully
• Actively listens and responds to feedback
• Adheres to strict confidentiality standards and protects sensitive information
• Supports organizational service standards
• Proficient in computer systems; experience with Epic preferred
• Ability to navigate multiple systems efficiently throughout the workday
• Demonstrates sound decision-making and ability to work independently with minimal supervision

Frequent movement within an office environment. Periods of prolonged sitting may be required.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.