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Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California, to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

The Prior Authorization Specialist serves the patients, staff, and clinicians of Oregon Medical Group by requesting prior authorization approvals for planned, scheduled, or rendered procedures, services, or medications. The Prior Authorization Specialist is responsible for the timely submission of all documentation, forms, or electronic requests in a timely fashion to not impede our community’s access to care.

Primary Responsibilities: 

• Obtains insurance prior authorization for patient prescriptions, treatments, services, or procedures and re-authorization for additional units including performing any retro-authorization requests as allowed by payers; appeal prior authorization denials and help facilitate peer-to-peer reviews as needed. Appropriately document authorization details in the patient’s medical record including notifying clinical staff of benefit limitations and authorization status
• Monitor pre-auth denials for trends and provider documentation issues, and escalate to Lead or Supervisor as appropriate
• Meet or exceed productivity expectations after orientation period to ensure requests are being processed timely
• Assist Operation teams with processing externally referred patients
• Ensure registration and insurance are accurately loaded into system, and make any necessary corrections
• Escalate any issues or concerns to the appropriate department or manager as necessary
• Maintain strictest confidentiality
• Work on assigned projects as needed
• Perform other duties as assigned

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualification:

• 1 years of experience in a medical billing office, medical office setting, or insurance company to include processing claims and a working knowledge of CPT, ICD-10, and HCPC coding

Preferred Qualification:

• Familiarity with payer authorization processes including interfacing with payers via calls, fax, or portals