Job Description

Position Summary:

The Prior Authorization Specialist is responsible for obtaining and verifying insurance prior authorizations for medical procedures, diagnostic testing, medications, and referrals. This role ensures timely and accurate authorization to facilitate uninterrupted patient care and efficient revenue cycle operations.

Key Responsibilities:

• Initiate and track prior authorization requests with insurance carriers for services, procedures, medications, and referrals.
• Verify insurance coverage, benefits, and patient eligibility.
• Communicate effectively with providers, clinical staff, and patients regarding authorization status and requirements.
• Accurately document all communication and authorization outcomes in the patient’s medical record or EMR system.
• Follow up with insurance companies to ensure timely responses to pending requests.
• Appeal denied authorizations when appropriate and provide supporting documentation.
• Stay up to date with payer-specific rules, formularies, and medical necessity criteria.
• Collaborate with billing and coding teams to minimize claim denials and delays.
• Maintain confidentiality and comply with HIPAA regulations at all times.

Required Qualifications:

• High school diploma or equivalent (Associate’s or higher preferred)
• 1–2 years of experience in medical insurance verification, authorizations, or related field
• Familiarity with insurance carriers (Medicare, Medicaid, commercial plans)
• Working knowledge of medical terminology, CPT/ICD-10 codes, and EMR systems
• Excellent attention to detail and organizational skills
• Strong communication and customer service skills
• Ability to work independently and manage multiple tasks efficiently

Preferred Skills:

• Experience with ePA systems (Electronic Prior Authorization)
• Familiarity with specialty medications and durable medical equipment (DME)
• Bilingual (if applicable to patient population)

Work Environment:

• Office or clinic setting
• May require occasional remote work depending on clinic policy
• Fast-paced, deadline-driven environment

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