Pre-Authorization Specialist (Clinic)

Premier Medical Resources•Houston, TX

2d•Hybrid

About The Position

Revenue Cycle Management is seeking a full-time Pre-Authorization Specialist. The role is primarily responsible for overseeing accurate and timely pre-certifications, pre-authorizations, and referrals for services. Under the direction of the Revenue Cycle Manager, the specialist helps ensure that departmental processes are functioning appropriately. The position offers a hybrid opportunity after 30–90 days of in-person training.

Requirements

High school diploma or GED.
Two years of experience in a medical office or facility setting.
Knowledge of in-network and out-of-network insurance, insurance verification, patient responsibility, and prior authorization processes.
Familiarity with ICD-10 and CPT codes and procedures.
Ability to review and understand patient medical documentation.
Ability to independently identify and understand medical necessity requirements.
Task-oriented and organizational skills, with the ability to complete tasks in a timely manner.
Attention to detail and thoroughness in completing work tasks.
Ability to work independently and as part of a team.
Ability to adapt flexibly.
Effective written and verbal communication skills.
Ability to use downtime efficiently and remain aware of team members’ workloads.

Responsibilities

Prioritize incoming authorization requests according to urgency.
Generate, verify, and oversee the complete procedure authorization and referral process.
Manage and resolve day-to-day pre-authorization issues as needed.
Monitor provider network status and notify appropriate individuals when providers are out of network.
Obtain authorizations by fax, payer website, or phone, and regularly follow up on pending cases.
Notify appropriate departments of approvals and denials.
Initiate and assist with appeals for denied authorizations.
Coordinate Peer-to-Peer (P2P) requests with the appropriate department.
Confirm the accuracy of CPT and ICD-10 diagnoses in procedure orders.
Contact patients as needed to discuss authorization status.
Maintain, monitor, and update payer medical policy guidelines to manage authorization requirements.
Request, review, and submit necessary patient documentation.
Assist with patient scheduling and inquiries as necessary.
Apply ICD-10, CPT, modifiers, and other codes according to coding guidelines.
Communicate with providers and other appropriate parties about missing information, including CPT codes, diagnosis codes, documents, and clinical reports, to ensure proper authorization processing.
Communicate with other departments about changes or updates to patient accounts and status.
Manage account status and identify inconsistencies.
Respond to billing inquiries.
Communicate company goals, expectations, updates, and deadlines in a timely manner.
Recommend workflow improvements as needed.
Report statistics as required.