Prior Authorization Specialist
POSITION OVERVIEW:
The Prior Authorization Specialist is responsible for obtaining and verifying prior authorizations for medical services, procedures, and medications. This role ensures timely and accurate processing of authorizations to support patient access to care and optimize reimbursement. The specialist works closely with the prior authorization nurse, providers, payers, and clinical teams to navigate insurance requirements and reduce delays in care.
QUALIFICATIONS:
- Associate’s degree in healthcare administration or related field preferred
- High school diploma or equivalent required
- 1–2 years of experience in healthcare, insurance verification, or prior authorization.
- Strong understanding of medical terminology, CPT/ICD-10 codes, and insurance processes.
- Experience with HER systems (Epic preferred), Microsoft Office, Excel and other web-based programs including CoverMyMeds
- Excellent communication, organizational, and time management skills.
- Certification as a PACS (prior authorization certified specialist) is a plus
ACCOUNTABILITY:
Reports to the Prior Authorization Manager and Revenue Cycle Director
DIRECT REPORTS:
None
POSITION-SPECIFIC REQUIREMENTS:
Key Responsibilities
- Review provider orders and documentation to determine if prior authorization is required
- Verify insurance eligibility and benefits as part of the authorization process
- Submit prior authorization requests to payers via portals, fax, or phone
- Track status and follow up on pending authorizations
- Communicate with providers and departments about prior authorization status
- Collaborate with clinical staff to obtain additional documentation when needed
- Maintain up-to-date knowledge of payer policies and authorization guidelines
- Escalate denials or complex cases to appropriate clinical or supervisory staff
- Participate in audits, quality improvement initiatives, and team meetings
- Perform additional responsibilities as requested by leadership to support departmental goals and hospital operations
Core Competencies
- Attention to detail and accuracy
- Problem-solving and critical thinking
- Team collaboration
- Customer service oriented
- Adaptable and takes initiative
WORK ENVIRONMENT:
- Works in a well-illuminated, climate-controlled environment
- May come in contact with hazardous chemical or treatment modalities
- Possibility exists of exposure to communicable diseases
- Involvement in inpatient care may result in unavoidable work-related illness or injury
- Work environment is comfortable, with minimal exposure to physical hazards
- Moderate to loud noise environment when machines/equipment in use
- Involvement in checking in/moving of supplies may result in unavoidable work-related injury
- Must be constantly alert for patient/family emergency situations
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