Prior Authorization Specialist

Prior Authorization Specialist

The Prior Authorization Specialist is responsible for coordinating and obtaining insurance authorizations and pre-certifications for patient visits, diagnostic services, procedures, and other covered healthcare services across multiple clinical specialties. This position works collaboratively with providers, clinical staff, insurance payers, and patients to ensure authorization requirements are met prior to services being rendered.

Utilizing multiple payer portals, electronic health records, and other technology platforms, the Prior Authorization Specialist submits, tracks, and manages authorization requests while ensuring compliance with payer requirements and organizational policies. This position plays a vital role in supporting timely patient access to care, minimizing delays in treatment, and promoting accurate reimbursement.

A Day in the Life:

• Reviews scheduled services, referrals, and provider orders to determine insurance authorization requirements.
• Obtains and manages prior authorizations and pre-certifications for patient visits, diagnostic services, procedures, and other covered healthcare services across multiple clinical specialties.
• Utilizes multiple commercial, Medicare, Medicaid, and managed care payer portals to submit, monitor, and maintain authorization requests.
• Reviews clinical documentation for completeness and medical necessity to support authorization requests and collaborates with clinical staff to obtain additional information as needed.
• Tracks authorization requests from submission through determination, documenting authorization status, reference numbers, effective dates, and applicable service limitations in the electronic health record and other designated systems.
• Communicates authorization approvals, denials, pending requests, and payer requirements to providers, clinical staff, scheduling personnel, and patients, as appropriate.
• Coordinates additional documentation, reconsiderations, appeals, or peer-to-peer review requests when required by the payer.
• Monitors authorization expiration dates, visit limits, and service utilization to ensure continued coverage when applicable.
• Maintains current knowledge of payer-specific authorization requirements, coverage guidelines, and regulatory changes.
• Identifies opportunities to improve authorization workflows and communicates trends or concerns to the HIM Supervisor.
• Ensures compliance with HIPAA, organizational policies, payer requirements, and applicable federal and state regulations.
• Performs other duties as assigned.

Core Competencies:

Customer Service: Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.

Communication: Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.

Dependability: Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.

Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems.

Productivity: Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, and handles information flow.

Requirements:

Success Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:

Required:

• Minimum of two (2) years of experience in prior authorization, revenue cycle management, referral management, or health information management.
• Experience working with commercial, Medicare, Medicaid, and managed care insurance plans.
• Experience working with electronic health records (EHR) and multiple payer or insurance portals.
• Basic knowledge of medical terminology, insurance verification, and prior authorization processes. Proficient computer skills, including Microsoft Office and the ability to learn new software applications.
• High school diploma or equivalent required.

Preferred:

• Experience in a multi-specialty healthcare practice or Federally Qualified Health Center (FQHC).
• Experience using NextGen EHR.

Language Skills:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of an organization.

Reasoning Ability:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills:

To perform this job successfully, an individual should have the ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, text paging, Internet, and Intranet.

Certificates, Licenses, Registrations:

None required for this position.

Other Applicable Requirements:

Ability to speak Spanish desirable. Skill with patients in lower socio-economic sectors of the community.

Physical Demands:

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

While performing the duties of this job, the employee is frequently required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to sit and stoop, kneel, crouch, or crawl. The employee must regularly lift and /or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is occasionally exposed to fumes or airborne particles; toxic or caustic chemicals and risk of radiation. The noise level in the work environment is usually moderate.

Affirmative Action/EEO Statement:

It is the policy of Primary Health Solutions to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.