Eligibility, Benefits, & Prior Authorization Specialist

Autism Diagnosis Group • ,

2d • $600 - $800 • Remote

About The Position

Josi Health is a fast-growing, virtual-first healthcare company dedicated to making neurodivergent care (including evaluations & therapy) faster, more accessible, and stress-free for families. We operate across 40+ states, navigating a complex landscape of commercial insurance carriers and state Medicaid programs. Because our clinical model is virtual-first, having bulletproof front-end patient access and benefit structures is critical to preventing administrative delays and billing denials.

We are seeking a highly analytical, detail-obsessed Eligibility, Benefits, & Prior Authorization Specialist who loves the investigative side of healthcare administration. In this role, you will not just perform data entry. You will act as an internal researcher and gatekeeper, digging into payor portals, insurance policy and benefits updates, and clinical guidelines to uncover the exact steps needed to secure prior authorizations and verify complex telehealth benefits.

This role is a blend of high-velocity queue management and deep-dive policy research. You will review incoming clinical orders, cross-reference them with payer requirements, clear daily scheduling queues, and build process playbooks where none exist. If you thrive on solving insurance puzzles, de-escalating complex scheduling bottlenecks, and keeping clinical schedules perfectly authorized, you will excel here.

Requirements

• 2+ years of healthcare clinic or startup experience specializing in insurance verification and prior authorizations
• Strong research capabilities: deep comfort navigating payor portals, digging through policy manuals, and calling payor representatives to clarify ambiguous rules
• Hands-on experience working with multiple major commercial payers (e.g., BCBS, Optum, Aetna)
• Working knowledge of medical terminology, CPT, ICD-10, and telehealth billing modifiers
• Excellent written and verbal English communication skills: ability to translate technical insurance terms into simple, clear explanations
• High-speed internet, backup power setup, and the ability to work full-time during EST business hours

Nice To Haves

• Medicaid familiarity is a plus
• Experience in virtual care, digital health, or behavioral/mental health environments
• Experience utilizing modern EHRs (e.g., Athenahealth) or CRM systems (e.g., Salesforce)
• Experience building internal SOPs or process documentation from scratch

Responsibilities

• Verify active patient insurance coverage, deductibles, co-pays, co-insurance, and coordination of benefits (COB) across commercial plans
• Conduct in-depth research on payer-specific policies regarding virtual care, remote developmental pediatrics, and psychological evaluations (CPT 90791, 96130, etc.)
• Navigate payor websites, newsletters, and provider manuals to track and document shifting policy guidelines and billing modifiers across 40+ states
• Review incoming clinical diagnostic referrals and orders to ensure demographic, insurance, CPT, and ICD-10 data are flawless
• Initiate, track, and validate prior authorizations through clearinghouses (e.g., Availity, Waystar), insurance portals, and phone escalations
• Ensure all authorizations are secured, confirmed accurate, and fully documented in the EMR before the close of business each day for upcoming clinics
• Act as the go-to resource for clinical teams when a payer's prior-authorization process is vague, contradictory, or unmapped
• Validate conflicting information from multiple insurance sources to determine the most credible, risk-free path for claim submission
• Build, update, and maintain internal state-by-state reference guides on commercial insurance and state-by-state regulatory requirements
• Prepare clear, professional patient insurance benefit letters outlining estimated out-of-pocket costs and referral requirements
• Collaborate closely with clinic coordinators and clinical staff to resolve last-minute scheduling exceptions or authorization gaps
• Help de-escalate patient or provider concerns regarding coverage limits with professional, empathetic communication

Benefits

• 100% remote work from anywhere outside the US
• Competitive monthly compensation in USD
• The opportunity to join a fast-growing, mission-driven team with clear professional growth
• Full access to modern operational tools and tech

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed