Prior Authorization Specialist

POSITION SUMMARY

The Prior Authorization Specialist works with all departments and insurance companies to obtain the necessary authorizations for services or medications that require prior-authorizations. Once received, authorization is communicated to staff and recoded into the EHR system to ensure proper billing. The Prior Authorization Specialist must maintain a high level of understanding of insurance companies and billing authorization requirements.

ESSENTIAL RESPONSIBILITIES

• Coordinates prior-authorization for procedures, orders, or medications by verifying the correct authorization form, obtaining all necessary information to complete form, and submitting the form to the correct insurance plan.

• Works with patients and insurance companies to secure retroactive insurance coverage and authorizations.

• Tracks and follows up on all pending authorizations or requests for additional information depending upon payer guidelines to expedite the claim process.

• Notifies appropriate staff of approved medical or medication authorizations and enters approved authorizations into the EHR.

• Works closely with Utilization Review Coordinator, billing, providers, and clinical teams.

• Knowledgeable in inpatient and outpatient coding, including and understanding of behavioral health, medical and psych procedures, ICD-10-CM, CPT, HCPCS, primary care, and residential.

• Displays a courteous, professional, and positive demeanor with co-workers and others while performing essential duties.

• Promotes effective working relations, both within the department and with other departments, to facilitate the department and organization’s ability to meet its goals and objectives.

· Manages the end-to-end credentialing and recredentialing process for medical providers and clinically licensed therapists with Medicare, Medicaid, and commercial insurance payers.

· Maintains accurate and up-to-date records, ensuring compliance with all payer requirements, regulatory standards, and accreditation bodies.

· Coordinates and completes credentialing applications for Polara Health’s clinics and hospital facilities, including licensing, certifications, and insurance panel enrollments.

· Serves as a liaison between providers, internal departments, and external agencies to resolve credentialing issues and ensure timely approvals.

· Performs other duties as required.

QUALIFICATIONS

· 21 years of age or older; or minimum 18 years old and licensed or certified under A.R.S. Title 32 and providing services within the personnel member’s scope of practice; or minimum 18 years old for select administrative positions

· Must be able to provide or obtain an AZDPS Level One Fingerprint Clearance Card

· Must possess and maintain a valid Driver License, current automobile insurance, and a driving record that meets the guidelines and requirements of the organization

• Minimum of a High School Diploma or GED required
• Must have one year of medical insurance verification or prior-authorizations related experience
• Knowledge of insurance terms and reimbursement procedures
• Excellent verbal and written communication skills required
• Excellent telephone etiquette
• Must have the ability to cooperate and collaborate as part of a team, taking action that indicates consideration for others
• Must be able to apply common sense reasoning and decision-making to carry out detailed, involved billing transactions and to resolve problems involving several concrete variables
• Must work assignments on time and readily accept assignments from supervisor
• Must be able to adhere to strict confidentiality

CORE COMPETENCIES

· People – Passionately believes in people and embraces diversity

· Integrity – Does the right thing even when no one is looking

· Learning – Challenges old paradigms with critical thinking, curiosity and creativity

· Accountability – Sets an intentional culture of personal responsibility; believes everyone carries the load

· Relationships – Serves colleagues and consumers with love, empathy and compassion

PHYSICAL DEMANDS & WORKING CONDITIONS

The physical and working demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

· Office environment, travel within the community, as needed

· Heavy exposure/use of computers, cell phones, office phones, etc.

· Ability to sit for prolonged periods throughout work hours

· Must be able to occasionally lift and/or move 5 or more pounds

· Must be able to respond appropriately and effectively in crisis situations by using good judgment and following Polara Health protocols

This position is considered Safety-Sensitive by Polara Health.

Polara Health subscribes to the principles of Equal Employment Opportunity. Polara Health’s policy is to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to ancestry, age, color, disability, genetic information, gender identity, gender expression, marital status, medical condition, military or veteran status, national origin, pregnancy, race, religion, sex/gender, sexual orientation, or any other basis prohibited by federal, state, or local law. As an Equal Opportunity Employer, Polara Health intends to comply fully with applicable federal, state, and local employment laws, and the information requested on this application will be used only for purposes consistent with those laws.

In accordance with requirements of the Americans with Disabilities Act, Polara Health’s policy is to provide reasonable accommodation for applicants requesting accommodation(s) during the application process, so the applicant may be given a full and fair opportunity to be considered for employment. If any candidate needs a reasonable accommodation to participate in the interview process, please notify Polara Health in any of the following ways: by calling View phone number on click.appcast.io, U.S. Mail, or hand deliver to Polara Health 3343 N. Windsong Drive, Prescott Valley, AZ 86314 Attention: Human Resources Job Applicant Request.

Employment is contingent on background checks as required by Polara Health’s policies, which may include Fingerprint Clearance, Drug Test, Criminal History, Driving History Record, Sex Offender Registry Search, Department of Child Services, State Central Registry Check, Employment Verification, Education Verification, and Professional References.

We Offer the Following Benefits to Full Time Employees:

Medical * Dental * Vision * Short and Long Term Disability * Life Insurance * Health Savings Account * Flexible Spending Account * Employee Assistance Program * 401(k) * Up to 3 Weeks of Paid Time Off * 10 Paid Holidays per Year * Shift Pay (for select inpatient and residential positions) * Educational Reimbursement *

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities


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.