Prior Authorization Specialist: Certified Medical Assistant (CMA) or Licensed Practical Nurse (LPN)

Department: Prior Authorization

Hours: Fulltime, Day Shift, Monday-Friday

Description:

Position Overview: The Prior Authorization Specialist is responsible for obtaining timely and accurate insurance authorizations and referrals for services rendered at a Rural Health Clinic (RHC) and an Outpatient Specialty Department (OSD). This role ensures compliance with payer guidelines and contributes to efficient patient access and revenue cycle processes. The specialist will work closely with providers, schedulers, billing teams, and insurance companies to prevent denials and delays in care.

Hybrid: Onsite and Remote/Work from Home

Essential Duties and Responsibilities:

• Verify insurance benefits and determine prior authorization or referral requirements for scheduled services.
• Initiate and follow through on all authorization requests for diagnostic testing, specialty consultations, outpatient procedures, and medications.
• Communicate with insurance carriers, third-party payers, and other entities to secure authorizations prior to service delivery via payer portals or telephone.
• Accurately enter and track authorization data in the Electronic Health Record (EHR) and scheduling systems.
• Collaborate with clinical staff to obtain necessary documentation to support medical necessity and authorization requests.
• Monitor authorization turnaround times and proactively follow up on pending or denied requests.
• Notify scheduling or clinical teams of any issues that may impact appointment times or patient care.
• Maintain thorough documentation of authorization requests, approvals, and correspondence.
• Assist in denial prevention efforts and provide feedback to billing and coding teams regarding authorization requirements.
• Educate staff and providers on payer-specific authorization protocols and updates.
• Support both the RHC and specialty clinic operations by flexibly covering requests from multiple service lines.
• Ensure all Health Insurance Portability and Accountability Act (HIPAA) and compliance regulations are followed in all communications and documentation.
• Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.

Minimum Education and/or Experience Required:

• High school diploma or equivalent.
• Two years’ experience in a medical related field required.
• Two years’ medical prior authorization experience preferred.

Additional Qualifications:

• Knowledge of insurance verification, prior authorization processes, and payer policies (Medicare, Medicaid, commercial plans). Understanding of how the prior authorization process directly impacts the organizations’ revenue cycle.
• Proficient in Microsoft Office (Word, Excel, Outlook). Proficient in navigating websites and using the internet.
• Excellent oral and written communication skills required.
• Must be able to read, write, comprehend, and verbally communicate in English fluently.
• Integrity and ability to work independently. Initiative to take on tasks without being told.
• Ability to manage multiple tasks across different departments or locations.
• Strong attention to detail and organizational skills.
• Adaptive to change, embraces change with optimism.
• Ability to problem solve, critically think.
• Ability to prioritize assignments and manage time efficiently.
• Ability to operate technologies and equipment associated with this position.
• Must have a service mindset and a commitment to continuous learning.
• Ability to work outside of regularly scheduled hours if needed.
• Mandatory Reporter.

Licensure/Certification Required:

• Current certification as a Certified Medical Assistant (CMA) through the American Association of Medical Assistants (AAMA), an equivalent medical assistant credential, or current licensure as a Licensed Practical Nurse (LPN) in the State of Iowa.

Physical/Cognitive Requirements:

• Sit: Constant
• Stand: Frequent
• Walk: Frequent
• Lift:
  • 10 pounds Frequent
  • 25 pounds: Frequent
  • 50 pounds*: Occasionally
  • 75 pounds*: Never
  • Greater than 100 pounds*: Never
• Carry:
  • 10 pounds: Frequent
  • 25 pounds: Frequent
  • 50 pounds*: Occasionally
  • 75 pounds*: Never
  • Greater than 100 pounds*: Never
• Push/Pull:
  • 10 pounds: Frequent
  • 25 pounds: Frequent
  • 50 pounds*: Occasionally
  • 75 pounds*: Never
  • Greater than 100 pounds*: Never
• Squat/Kneel/Crouch: Occasionally
• Climb: Occasionally
• Balance: Occasionally
• Twist: Occasionally
• Bend/Stoop: Occasionally
• Crawl: Occasionally
• Grasp/Grip: Frequent
• Talk: Constant
• Hear: Constant
• See: Constant

• Anything greater than 50 pounds- assist of two or more, or mechanical lift are required.

Environmental Factors:

• May be exposed to communicable diseases due to working in a health care environment.
• Works in a well-illuminated climate-controlled environment.
• Moderate noise level when machines/equipment in use but typically quiet environment.

Organizational Relationships:

Reports to: Patient Access Manager

Employees supervised: None