Job Description

POSITION SUMMARY

The Prior Authorization Specialist plays a critical role in an effective prior authorization program. This position ensures patients receive timely and appropriate medical services by securing insurance approvals for procedures, treatments, and hospital admissions. This position requires a deep understanding of insurance guidelines, medical terminology, and healthcare workflows to facilitate efficient and accurate authorization processes.

ESSENTIAL JOB DUTIES & RESPONSIBLITIES

• Contact patient insurance companies to verify patient insurance and benefits for scheduled services and hospital admissions
• Obtain, process and document prior authorizations in the electronic medical record (EMR) including authorization numbers, CPT codes, diagnosis, and approval dates
• Submit supporting medical records and necessary information to payer authorization representatives via fax, phone, or online portals
• Stay up to date with payer trends for prior authorizations
• Prioritize workload to ensure urgent cases are handled in a timely manner
• Ensure timely and accurate insurance authorizations are in place prior to services being rendered
• Maintain accurate payer website information and logins
• Communicate regularly with other departments and educate staff on authorization needs
• Develop and maintain working relationships with external agencies and specialty providers
• Explain notice of non-coverage or offers to re-schedule elective tests and procedures, when patient pre-authorization is not obtained; notify patient and physician of outcome
• Ensure urgent/emergent cases are worked within one business day & elective cases prior to date of service
• Serve as liaison to hospital departments, physician offices, and patients for authorization or financial responsibility questions
• Facilitate authorization process with offices and providers
• Obtain clinical information from physician offices and HIM for CPT/ICD-10 codes
• Monitor prior authorization outcomes and maintain awareness of approvals and any denials resulting from inaccurate or incomplete information, communicating with Patient Accounting and the Revenue Cycle Action Team as needed.
• Connect patients/guarantors to Financial Counselor for estimates
• Maintain professional growth through seminars, workshops, and affiliations
• Participate in meetings, committees, and department projects as needed

Hours: Minimum 40 hours/week; Monday-Friday 8:00am - 4:30pm

Education, Experience:
High school diploma or equivalent
Experience in insurance verification or prior authorizations
Familiarity with health insurance plans, ICD/CPT coding, and EMR systems
Strong organizational and customer service skills
Proficient in computer navigation, word processing, and email

Certificates, Licensure, Registrations:
None

GENERAL REQUIREMENTS

Basic math and reading comprehension
Ability to use computer systems and write reports
Adaptability and problem-solving skills
Strong interpersonal and communication abilities

EQUIPMENT, TOOLS, MATERIALS

Knowledge of relevant computer hardware and software

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