Prior Authorization Specialist

Job Duties and Responsibilities:

• Verify the patient’s medical and pharmacy coverage/benefits to confirm authorization requirements via system and/or insurance portals.
• Validating Authorization requirement on Durable Medical Equipment (DME) for Urological and Catheter products, Incontinence supplies, thickeners, and nutritional supplements, Breast pumps and other healthcare related products for 150+ insurances/Payers.
• Submit Authorization request to appropriate Insurance based on patient’s coverage whether through call, portal, or fax accurately.
• Validates the status of Authorization request through call, portal, or fax accurately.
• Initiate outbound calls to Insurances to validate benefit information and request Authorization, check for status, follow-up, and/or re-initiate authorization as necessary.
• Manages an average of 1000+ patient accounts per month.
• Maintains accurate and detailed records in company database.
• Adapts quickly to frequent process changes and improvements.
• Is reliable, engaged, and provides feedback to improve processes and policies.
• Attends all department, team, and weekly company meetings as required.
• Perform any additional responsibilities or special projects as required.
• Duties and responsibilities may be subject to change based upon the needs of the department.
• Prior Authorization (PA) Processing
  Initiate prior authorization requests based on payer requirements identified during verification.
  b. Compile and submit all required documentation, including physician orders, clinical notes, and supporting medical necessity documentation.
  c. Coordinate with physician offices for any missing or incomplete documentation.
  d. Submit authorization requests via payer portals, fax, or phone as required.
• Authorization Follow-Up & Resolution
  Track authorization status and perform timely follow-ups with payers to ensure approvals are obtained within required turnaround times.
  b. Resolve pended or denied authorizations by addressing payer requests for additional information.
  c. Escalate complex cases or repeated denials as needed for client review.
  d. Document authorization approvals, reference numbers, and validity periods accurately.

Job Required Qualification:

• Minimum 3-year solid experience with US Healthcare Insurance
• At least 1 year work experience in a customer service call center (Voice and Back office)
• Experience with medical Insurance/Benefits investigation and Authorizations is highly preferred.
• Excellent Customer service skills, including phone and interpersonal skills.
• Computer proficiency in MS Word, Excel, and Outlook preferred
• Typing accuracy of 35 wpm minimum
• Database data entry experience preferred.
• Strong knowledge and use of the English language, both written and verbal
• Work history of excellent attendance and punctuality
• High comfort level working with culturally diverse team members and clients.
• Proficient mathematical skills, including addition, subtraction, multiplication, and division.

Preferred Qualifications:

• Startup / rapid growth experience
• Life sciences, pharmaceutical, or medical device experience.
• Knowledge of medical terminology preferred.
• Knowledge on Durable Medical Equipment