Prior Authorization Department

Position Title

Prior Authorization Specialist / Prior Authorization Coordinator

Department

Prior Authorization Department

Job Summary

The Prior Authorization Specialist is responsible for obtaining insurance authorizations and approvals for medical services, treatments, medications, procedures, and equipment. This role works closely with physicians, clinical staff, insurance companies, and patients to ensure timely approvals and accurate documentation while maintaining compliance with payer guidelines and company policies.

Essential Duties and Responsibilities

• Submit prior authorization requests to insurance providers for medical services, medications, procedures, and treatments
• Verify patient insurance eligibility and benefits
• Review clinical documentation to ensure authorization requirements are met
• Communicate with physicians, nurses, pharmacies, and other departments regarding authorization status and additional documentation needs
• Follow up with insurance companies on pending, denied, or incomplete authorizations
• Process authorization renewals and extensions as needed
• Document all authorization activities accurately in the EMR/EHR system
• Maintain knowledge of insurance payer guidelines, Medicare, Medicaid, and commercial insurance requirements
• Assist with appeals and denial management when authorizations are denied
• Ensure all approvals are obtained prior to scheduled services when required
• Maintain confidentiality of patient information in compliance with HIPAA regulations
• Provide excellent customer service to patients and internal staff

Qualifications

• High school diploma or equivalent required; associate degree preferred
• Minimum of 12 years of experience in healthcare, medical billing, insurance verification, or prior authorization preferred
• Knowledge of medical terminology, CPT, ICD-10, and HCPCS coding preferred
• Experience with EMR/EHR systems and insurance portals
• Strong organizational and multitasking skills
• Excellent communication and problem-solving abilities
• Ability to work independently and in a fast-paced environment
• Proficiency in Microsoft Office applications

Preferred Experience

• Experience in Home Health, Hospice, Specialty Pharmacy, or Medical Office settings
• Familiarity with Medicare, Medi-Cal/Medicaid, and commercial payer authorization processes

Physical Requirements

• Prolonged periods of sitting and computer work
• Ability to communicate effectively by phone and email
• Occasional lifting of office materials up to 15 pounds

Work Environment

• Office or healthcare setting
• Standard business hours with occasional overtime depending on authorization volume

Skills

• Attention to detail
• Time management
• Insurance verification and authorization processing
• Data entry accuracy
• Customer service
• Team collaboration