Prior Authorization & Utilization Specialist (100% Remote)

Are you an experienced healthcare professional with a sharp eye for detail and a strong background in prior authorizations? We are seeking a highly organized, detail-oriented Prior Authorization Specialist to join our national Utilization Management team.

In this role, you will serve as a vital link in the member care pipeline by managing authorization request queues, verifying member eligibility, gathering medical documentation, and routing requests to clinical reviewers. You will directly support timely access to care by processing approvals and matching members with the appropriate healthcare providers in accordance with strict contractual timelines.

Position Type: Full-Time | 100% Remote

Schedule: Monday – Friday, 8:00 AM – 5:00 PM CST (Must live in this time zone)

Core Responsibilities

• Queue & Task Management: Actively monitor, review, and process incoming prior authorization requests and referrals from the assigned queue within required contractual timelines.
• Provider & Member Matching: Process member approvals accurately to match members with qualified providers and ensure seamless access to healthcare services.
• Eligibility & Benefit Verification: Verify member insurance coverage, benefit eligibility, and authorization guidelines using digital system tools to support timely claim adjudication and payment.
• Information & Medical Data Gathering: Research and compile key medical documentation (including patient history, diagnosis, and prognosis) to support clinical reviewers during determination.
• Data Entry & System Tracking: Accurately enter and update authorization records in the utilization management system, maintaining ongoing tracking in compliance with operational guidelines.
• Clinical Workflow Routing: Identify services on the prior authorization list and route complex cases directly to the appropriate clinical review staff.
• Quality & Compliance Adherence: Stay current on healthcare guidelines, authorization workflows, and compliance policies to ensure full adherence to organizational standards.

Key Performance Expectations & Metrics

To ensure optimal service and regulatory compliance, candidate performance is measured against high-quality standards:

• Audit Accuracy: Maintain a 95% or higher pass rate on quality audits.
• Error Rate: Maintain a maximum error rate of 2% or lower across all authorization processing and data entry tasks.

Qualifications & Requirements

• Education: High School Diploma or GED required.
• Experience: Minimum of 2+ years of prior authorization experience in a healthcare, health plan, or utilization management environment.
• Location & Hours: 100% Remote nationwide; candidate must work Monday through Friday, 8:00 AM – 5:00 PM CST .
• Medical Knowledge: Working knowledge of medical terminology, insurance concepts, and authorization guidelines.
• Technical Skills: Strong computer literacy with proven experience navigating electronic authorization systems, queue management platforms, and data entry tools.
• Soft Skills: High attention to detail, strong organizational skills, and excellent written and verbal communication abilities.

Why Apply?

• Fully Remote Flexibility: Work from home from anywhere in the U.S. with a consistent Monday–Friday schedule.
• No Pre-Employment Skills Assessment Required .
• Impactful Work: Directly support member health outcomes by ensuring fast, accurate authorization processing.