Prior Authorization Specialist - Specialty

About the Role:

The Prior Authorization Specialist - Specialty plays a critical role in the healthcare delivery process by ensuring timely and accurate authorization of acute medical services. This position involves collaborating closely with healthcare providers, insurance companies, and patients to facilitate the approval of necessary treatments and procedures. The specialist is responsible for reviewing clinical documentation, verifying insurance benefits, and navigating complex payer requirements to expedite care without compromising compliance. By efficiently managing prior authorization requests, this role directly impacts patient outcomes and satisfaction by reducing delays in receiving acute care services. Ultimately, the Acute Prior Authorization Specialist serves as a vital liaison that supports both clinical teams and administrative operations within the healthcare system.

Roles and Responsibilities

• The primary role of the Authorization Specialist is to review, process, and follow to completion the requirement of obtaining prior authorization for services. This excludes PBM authorizations.
• Coordinates with the Intake Specialists and the Clinical Review Team to identify and process requests for services requiring Prior
• Authorization and/or Pre-Determination for services rendered.
• Assists the Clinical Review Team as necessary to obtain authorizations for specialty and complicated therapies.
• Reviews each request for Prior Authorization and insures that the proper supporting documentation and forms/documents are completed.
• Processes Prior Authorizations via Fax, computer or phone call as required by the specific payers.
• Maintains an organized process for documenting and tracking all requested prior authorizations.
• Maintains an organized process for timely follow-up and troubleshooting of all pending Prior Authorizations.
• Documents in the patient record all prior authorizations, expiration dates and other information as required.
• Communicates with the Clinical Review Team and Admission Specialists any prior authorization denials and insures prompt follow-up.
• Maintains a process to review newly accepted patients for a “second check” to prevent missing prior authorization requests.
• Effectively identify and communicate to supervisor when assistance is needed (including, but not limited to system function, training, etc.)
• Observes legal and ethical guidelines for safeguarding patient and company confidentiality (HIPAA)
• Understands and provides exceptional customer service to clients, patients, and payers.
• Exhibits a positive, courteous, respectful and helpful attitude to clients, co-workers, and management team.
• Promotes company culture by adhering to all policies and procedures
• Adapts to and demonstrates the ability to deal with frequent changes in the work environment.
• Other tasks/duties as assigned.
• Complete understanding of confidentiality with respect to Company proprietary information as well as information concerning patient/client care; complying with all federal and state laws as apply to confidentiality of protected health information (PHI) and electronic protected health information (EPHI); and following HIPAA guidelines regarding readily identifiable protected health information.

Qualifications and Experience

• Minimum of High School Diploma or GED.
• Knowledge of medical terminology preferred, but not required.
• Excellent organizational skills.
• Ability to work independently and stay on task, while maintaining the willingness to assist co-workers as needed.
• Ability to maintain accurate and detailed charts/notes in the company system.
• Ability to work independently and stay on task.
• Must possess excellent verbal and written communication skills.
• Ability to work under stressful conditions in a fast paced environment.
• Is a self starter and takes initiative to learn.