MA - Prior Authorization

BOONE MEMORIAL HOSPITAL INC•Madison, WV

9d•Onsite

About The Position

Boone Memorial Health is seeking a detail-oriented and organized Medical Assistant – Prior Authorization to coordinate prescription medication refill requests and insurance prior authorizations accurately and in a timely manner. The role works closely with providers, Medical Assistants, pharmacies, patients, and insurance companies, and serves as a liaison among these groups. The employee must maintain patient confidentiality and comply with HIPAA, clinic policies, and applicable laws and regulations. The position reviews and processes medication refill requests, checks relevant patient and clinical information, routes requests for provider approval when needed, and follows up on pending requests. It also processes prior authorizations by gathering clinical information, submitting requests, communicating with insurers, tracking decisions and deadlines, and assisting with appeals, documentation, and renewals. All related communications and actions must be documented in the electronic health record. Work is primarily in a medical clinic and office environment with frequent computer, telephone, and electronic health record use. The position involves managing multiple priorities and interruptions while maintaining accuracy and confidentiality. Occasional exposure to communicable illnesses and other healthcare-setting hazards may occur. There are no supervisory or travel requirements. Employees support patient safety, quality improvement, and organizational compliance.

Requirements

High school diploma or equivalent.
Current Medical Assistant (MA) certification through a nationally recognized credentialing organization, maintained active and in good standing throughout employment.
Maintain continuing education and renewal requirements associated with the MA certification.
Ability to learn and use insurance portals and electronic authorization systems.
Strong organizational, time-management, and problem-solving skills.
Excellent attention to detail.
Strong written and verbal communication skills.
Ability to communicate professionally with patients, providers, pharmacies, and insurance representatives.
Ability to prioritize multiple requests and meet established deadlines.
Ability to work independently and effectively as part of a clinical team.
Ability to maintain patient confidentiality and appropriately handle sensitive information.
Ability to sit and work at a computer for extended periods and communicate by telephone and electronic communication throughout the workday.
Ability to maintain accuracy while managing multiple tasks in a fast-paced medical office environment.

Nice To Haves

Previous healthcare, medical office, pharmacy, insurance, or prior authorization experience.
Knowledge of medical terminology and prescription medications.
Experience working with an electronic health record.
Current Basic Life Support (BLS) certification, if applicable to assigned duties.

Responsibilities

Receive, review, and process medication refill requests submitted by telephone, pharmacies, electronic messages, and other approved methods.
Review medication lists, allergies, recent office visits, upcoming appointments, and available clinical information before routing refill requests.
Process refills according to clinic protocols and provider instructions, and route requests to providers for approval when required.
Identify medications requiring an office visit, laboratory monitoring, or other clinical follow-up before authorization.
Contact patients about refill issues, required appointments or testing, and information needed to process requests.
Communicate with pharmacies about prescription clarifications, quantities, directions, and other nonclinical issues.
Follow up on pending refill requests, monitor turnaround times, and notify clinical staff or providers about urgent medication concerns.
Document refill-related communications and actions accurately in the electronic health record.
Obtain and provide Board of Pharmacy reports to providers when requesting controlled substances.
Receive and process medication prior authorization requests from pharmacies, insurers, patients, and providers.
Review insurance requirements and gather clinical information from medical records and provider documentation.
Complete and submit prior authorization requests through insurance portals, electronic systems, fax, or telephone.
Communicate with insurance companies about authorization requirements and request status, and follow up on pending authorizations.
Notify providers when additional clinical information, documentation, or alternative medications are required.
Communicate authorization decisions to clinical staff and patients.
Assist with appeals, additional documentation, and patient assistance programs as requested.
Maintain an organized tracking system for pending, approved, denied, and appealed authorizations.
Monitor authorization expiration dates and assist with renewals.
Document authorization correspondence, decisions, and follow-up activities in the electronic health record.
Perform other duties as assigned by the Clinic Manager or Clinical Supervisor.
Support patient safety, quality improvement, and organizational compliance; report safety concerns, near misses, threats, and adverse events according to organizational procedures.
Follow applicable laws, regulations, accreditation standards, and organizational policies, including requirements related to patient rights, confidentiality, and privacy.