Prior Authorization Specialist - Clinical MA

ESSENTIAL FUNCTIONS:

• Review prior authorization requests for completeness, accuracy, and payer-specific requirements.
• Verify patient insurance eligibility, benefits, referrals, and authorization requirements.
• Submit authorization requests through electronic payer portals, fax, telephone, or other designated systems.
• Obtain, review, and submit required clinical documentation, medical records, test results, and supporting information.
• Communicate with insurance companies and other payers regarding authorization requirements, status, additional documentation, and determinations.
• Monitor and track pending authorizations and conduct timely follow-up to prevent delays in patient care.
• Accurately document authorization activities, communications, approvals, denials, and follow-up in the electronic medical record (EMR/EHR) and other applicable systems.
• Communicate authorization determinations and outstanding requirements to providers and appropriate clinical staff.
• Assist with prior authorization denials, reconsiderations, peer-to-peer requests, and appeals as appropriate.
• Coordinate with pharmacies, specialty services, diagnostic facilities, and other healthcare entities when authorization is required.
• Maintain confidentiality and comply with HIPAA, payer requirements, and organizational policies and procedures.
• Provide professional, timely, and respectful communication with patients, providers, insurance representatives, and internal departments.
• Identify opportunities to improve authorization processes, efficiency, communication, and quality.
• Perform other duties and responsibilities as assigned.

REQUIRED QUALIFICATIONS AND COMPETENCIES

Education and Certification

• High school diploma or GED required.
• Medical Assistant certification or equivalent healthcare education, training, and/or relevant experience required.
• Bachelor’s degree in healthcare administration, health sciences, or a related field preferred.
• Current BLS certification required.

Experience and Technical Knowledge

• Experience in a medical office, healthcare, insurance, referrals, prior authorization, patient access, or related setting preferred.
• Prior experience processing medical or pharmacy prior authorizations preferred.
• Knowledge of medical terminology and basic healthcare practices.
• Knowledge of insurance plans, benefits, referrals, and authorization processes.
• Familiarity with CPT, ICD-10, and HCPCS coding preferred.
• Experience using insurance portals, payer websites, and electronic authorization systems preferred.
• Experience with EMR/EHR systems required; experience with eClinicalWorks preferred.
• Strong computer, keyboarding, data entry, and document management skills.
• Ability to learn and effectively use new software, healthcare applications, and hospital/browser-based systems.

Communication and Interpersonal Skills

• Excellent written and verbal communication skills.
• Ability to communicate clearly and professionally with patients, providers, insurance representatives, and coworkers.
• Demonstrates active listening skills and responds appropriately to questions and concerns.
• Maintains professionalism, tact, and respect when interacting with others.
• Ability to work effectively as part of a multidisciplinary team.

Organizational and Problem-Solving Skills

• Strong attention to detail and accuracy.
• Ability to prioritize and organize multiple authorization requests and competing deadlines.
• Ability to work independently while appropriately escalating issues or concerns.
• Uses logic and reasoning to evaluate information, identify problems, and determine appropriate solutions.
• Demonstrates initiative and resourcefulness in resolving authorization issues.
• Adaptable to changes in workload, processes, payer requirements, and technology.
• Demonstrates a commitment to continuous improvement and identifies opportunities to enhance departmental efficiency and quality.