Prior Authorization Specialist - Clinical MA

Rowan Diagnostic Clinic, PA•Salisbury, NC

7d•Onsite

About The Position

This role is responsible for managing the prior authorization process for patients. Key duties include reviewing requests for completeness and accuracy, verifying insurance information, submitting authorization requests through various channels, and coordinating with healthcare entities. The specialist will maintain detailed records in the EMR/EHR system, communicate determinations to providers and staff, and assist with denials and appeals. The position also involves identifying opportunities for process improvement and maintaining confidentiality in accordance with HIPAA and other regulations. Professional and respectful communication with all stakeholders is essential.

Requirements

High school diploma or GED required.
Medical Assistant certification or equivalent healthcare education, training, and/or relevant experience required.
Current BLS certification required.
Knowledge of medical terminology and basic healthcare practices.
Knowledge of insurance plans, benefits, referrals, and authorization processes.
Experience using insurance portals, payer websites, and electronic authorization systems preferred.
Experience with EMR/EHR systems required.
Strong computer, keyboarding, data entry, and document management skills.
Ability to learn and effectively use new software, healthcare applications, and hospital/browser-based systems.
Excellent written and verbal communication skills.
Ability to communicate clearly and professionally with patients, providers, insurance representatives, and coworkers.
Demonstrates active listening skills and responds appropriately to questions and concerns.
Maintains professionalism, tact, and respect when interacting with others.
Ability to work effectively as part of a multidisciplinary team.
Strong attention to detail and accuracy.
Ability to prioritize and organize multiple authorization requests and competing deadlines.
Ability to work independently while appropriately escalating issues or concerns.
Uses logic and reasoning to evaluate information, identify problems, and determine appropriate solutions.
Demonstrates initiative and resourcefulness in resolving authorization issues.
Adaptable to changes in workload, processes, payer requirements, and technology.
Demonstrates a commitment to continuous improvement and identifies opportunities to enhance departmental efficiency and quality.

Nice To Haves

Bachelor’s degree in healthcare administration, health sciences, or a related field preferred.
Experience in a medical office, healthcare, insurance, referrals, prior authorization, patient access, or related setting preferred.
Prior experience processing medical or pharmacy prior authorizations preferred.
Familiarity with CPT, ICD-10, and HCPCS coding preferred.
Experience with eClinicalWorks preferred.

Responsibilities

Review prior authorization requests for completeness, accuracy, and payer-specific requirements.
Verify patient insurance eligibility, benefits, referrals, and authorization requirements.
Submit authorization requests through electronic payer portals, fax, telephone, or other designated systems.
Obtain, review, and submit required clinical documentation, medical records, test results, and supporting information.
Communicate with insurance companies and other payers regarding authorization requirements, status, additional documentation, and determinations.
Monitor and track pending authorizations and conduct timely follow-up to prevent delays in patient care.
Accurately document authorization activities, communications, approvals, denials, and follow-up in the electronic medical record (EMR/EHR) and other applicable systems.
Communicate authorization determinations and outstanding requirements to providers and appropriate clinical staff.
Assist with prior authorization denials, reconsiderations, peer-to-peer requests, and appeals as appropriate.
Coordinate with pharmacies, specialty services, diagnostic facilities, and other healthcare entities when authorization is required.
Maintain confidentiality and comply with HIPAA, payer requirements, and organizational policies and procedures.
Provide professional, timely, and respectful communication with patients, providers, insurance representatives, and internal departments.
Identify opportunities to improve authorization processes, efficiency, communication, and quality.
Perform other duties and responsibilities as assigned.