Prior Authorization Specialist

The Prior Authorization Specialist is responsible for verifying patient eligibility and insurance benefits for clinic-administered medications. This position requires a thorough understanding of insurance terminology, benefit structures, and authorization processes to ensure accurate documentation and timely completion of prior authorization requests. The Specialist will obtain, monitor, and maintain authorizations through payer websites, fax, and telephone, including all necessary follow-up and reauthorization activities. This role supports revenue cycle accuracy and contributes to the delivery of high-quality patient care.

Key Responsibilities:

• Initiate, monitor, and secure prior authorizations from third-party payers.
• Maintain electronic documentation for all prior authorization activities in accordance with organizational standards.
• Track pending authorizations and follow up within defined timeframes (7–10 days or payer-specific requirements) to support timely claims submission.
• Obtain authorization renewals and verify active provider orders and medical necessity documentation.
• Work collaboratively with clinicians, practice managers, and other team members to obtain clinical notes and documentation necessary for prior authorization approval.
• Verify authorization quantities and effective dates; ensure accurate processing by third-party payers and correct loading of information in internal systems.
• Review and confirm patient eligibility, insurance benefits, and plan requirements for clinic-administered medications.
• Interpret payer pre-certification and authorization guidelines and ensure appropriate approvals are obtained and documented.
• Input accurate Payer Plan ID numbers and related data into organizational systems to ensure correct billing for current and future services.
• Determine patient financial responsibility, including coordination of benefits and other coverage considerations.
• Organize workload and manage deadlines to prevent delays or loss of revenue due to filing limitations.
• Maintain professional communication with all payers, clinicians, and other team members.
• Perform additional duties as assigned.

 Qualifications:

• Prior experience in authorization processing and benefit investigation required.
• Experience with specialty medication authorizations preferred.
• Strong attention to detail and accuracy.
• Excellent time management and organizational skills.
• Proficiency in Microsoft Excel and related software applications.
• Strong interpersonal and communication skills.
• Ability to interpret insurance benefits, authorization guidelines, and medical terminology.
• Ability to work collaboratively in a fast-paced, team-oriented environment.