Prior Authorization Specialist - KOC Weisgarber

Knoxville Orthopaedic Clinic (KOC) is seeking an organized, detail-oriented Prior Authorization Specialist to join our Operations team. This position plays an important role in helping patients receive timely access to care by coordinating insurance authorization requirements for ordered services, procedures, medications, and durable medical equipment.

The Prior Authorization Specialist reviews insurance benefits and payer requirements, gathers necessary clinical documentation, submits authorization requests, and monitors each request through determination. This role works closely with patients, providers, clinical Team Members, scheduling, insurance payers, and other departments to communicate authorization status and resolve barriers that could delay care.

The ideal candidate is a strong communicator and problem-solver who is comfortable navigating insurance requirements, managing multiple pending requests, and following detailed authorization processes through completion.

What You'll Do

• Review patient orders, diagnoses, clinical documentation, insurance information, and payer requirements to determine when prior authorization is required.

• Verify insurance eligibility, benefits, coverage limitations, referral requirements, and payer-specific authorization criteria.

• Gather and organize supporting clinical documentation, including office notes, imaging, treatment history, test results, and other required information.

• Submit complete and accurate prior authorization requests through payer portals, telephone, fax, electronic systems, and other approved channels.

• Monitor pending authorization requests, payer correspondence, requests for additional information, determinations, expiration dates, visit limits, and scheduled service dates.

• Document authorization numbers, effective dates, approved services, limitations, denial reasons, actions taken, and required follow-up.

• Communicate authorization status, delays, denials, and required next steps to patients, providers, scheduling, and other affected Team Members.

• Coordinate peer-to-peer reviews, reconsiderations, appeals, and additional documentation requests as directed.

• Research denied, incomplete, or inconsistent authorization requests and work with clinical Team Members and insurance payers to resolve outstanding issues.

• Maintain organized work queues, correspondence, notes, deadlines, and supporting records and follow assigned requests through final resolution.

• Review authorization requests for completeness and accuracy before submission, update, or closure.

• Identify and escalate urgent access-to-care concerns, unresolved denials, repeated payer barriers, and other significant issues through established channels.

• Collaborate with clinical and administrative Team Members to help prevent authorization-related delays in patient care.

• Maintain patient confidentiality and protect sensitive clinical, financial, and organizational information.

• Follow payer policies, privacy requirements, established timelines, and KOC procedures.

• Participate in meetings, education, cross-training, reporting, audit support, quality-review activities, and special projects as assigned.

What We're Looking For

• High school diploma or equivalent required.

• Experience in prior authorization, insurance verification, referrals, medical scheduling, billing, or a comparable healthcare support role.

• Working knowledge of insurance benefits and payer authorization requirements.

• Familiarity with medical terminology, clinical documentation, and patient privacy requirements.

• Strong organization, communication, customer-service, and problem-solving skills.

• Excellent attention to detail and ability to accurately review clinical and insurance information.

• Strong follow-through with the ability to manage authorization requests from initial submission through final determination.

• Ability to manage multiple pending requests, competing priorities, recurring deadlines, and frequent payer follow-up.

• Professional communication skills when working with patients, providers, insurance representatives, and other Team Members.

• Ability to maintain confidential information with accuracy and discretion.

• Proficiency with electronic health records, practice-management systems, payer portals, spreadsheets, email, and common office applications.

Preferred Experience

• Associate or bachelor's degree in Healthcare Administration, Business, Health Information Management, or a related field.

• Previous experience in an orthopaedic organization, multi-site physician practice, or other complex healthcare environment.

• Experience obtaining prior authorizations across multiple insurance payers.

• Experience coordinating authorizations for procedures, imaging, medications, durable medical equipment, or other specialty services.

• Experience researching authorization denials, obtaining additional documentation, and coordinating peer-to-peer reviews or appeals.

Join the KOC Team

At Knoxville Orthopaedic Clinic, our purpose is to improve lives through patient-centered care — every patient, every time. Since our founding in 1930, KOC has remained committed to providing high-quality orthopaedic care and an exceptional experience for the patients and communities we serve.

As a Prior Authorization Specialist, you'll play an important role in helping patients move forward with the care they need by navigating insurance requirements, coordinating documentation, and working with providers and payers to prevent unnecessary delays.

If you are detail-oriented, organized, comfortable navigating insurance requirements, and committed to helping patients access care, we encourage you to apply and become part of the KOC team.

Knoxville Orthopaedic Clinic is an Equal Employment Opportunity (EEO) employer. We are committed to providing a positive work environment where all individuals are treated with respect and dignity. We do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected by law.