Description

The Prior Authorization Specialist is responsible for obtaining and managing prior authorizations for medical services, procedures, and medications as required by insurance companies. This role is crucial in ensuring that patients receive timely and appropriate care while maintaining compliance with insurance guidelines.

Requirements

Key Responsibilities:

• Review and process requests for prior authorization for medical services, procedures, and medications.
• Understand the differences between Buy and Bill vs. in-house billables for medication prior authorization.
• Utilize platforms such as Cover My Meds and Transact RX for managing prior authorizations.
• Manage the MA/Provider Inbox to ensure timely responses to inquiries and requests.
• Work with care gap lists provided by insurance vendors to identify and address gaps in patient care.
• Assist in closing care gaps identified by MCAWE (Medicare Advantage With Enhanced Benefits).
• Communicate with healthcare providers, insurance companies, and patients to gather necessary information for prior authorization requests.
• Verify insurance coverage and benefits for patients and inform them of any financial responsibilities.
• Track and follow up on pending prior authorization requests to ensure timely approval.
• Maintain accurate and up-to-date records of all prior authorization activities.
• Collaborate with healthcare providers and billing departments to resolve any issues related to prior authorizations.
• Educate patients and healthcare providers about insurance requirements and prior authorization processes.
• Stay current with changes in insurance policies and guidelines related to prior authorizations.

Qualifications:

• High school diploma or equivalent; Associate's or Bachelor's degree in healthcare administration or related field preferred.
• Medical Assistant certification is required.
• Minimum of 1-2 years of experience in a medical office or healthcare setting, with prior experience in prior authorization or insurance verification.
• Knowledge of medical terminology, coding (ICD-10, CPT), and insurance policies.
• Strong communication and interpersonal skills, with the ability to interact effectively with patients, healthcare providers, and insurance representatives.
• Excellent organizational and time-management skills, with the ability to multitask and prioritize tasks.
• Proficiency in electronic medical records (EMR) systems (Allscripts preferred) and Microsoft Office Suite.
• Detail-oriented with a commitment to accuracy and confidentiality.
• A commitment to excellence and a willingness to learn and grow.

Physical & Mental Requirements:

• Ability to lift up to 50 pounds
• Ability to push or pull heavy objects using up to 50 pounds of force
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• Ability to travel to multiple locations to support business needs as required