Prior Authorization Specialist

Vista Healthcare•St. George, UT

About The Position

The Prior Authorization Specialist supports the processing and authorization of medical procedures ordered by referring physicians. The role reviews orders and clinical information for completeness and insurance coverage, obtains missing documentation from physician offices, and works with insurers to secure pre-certification or authorization. The specialist monitors authorization status, communicates updates and denials to physicians, assists with peer-to-peer review scheduling when needed, and contacts patients about completed orders and next steps for scheduling. The position also requires accurate data entry, maintenance of authorization records, protection of patient confidentiality, and effective collaboration with patients, physicians, clinics, providers, and colleagues.

Requirements

Six months of previous experience in medical prior authorization; the employer will train the right person.
Knowledge of CPT and ICD-10 codes.
Familiarity with medical terminology.
High school education or GED.
Ability to interact with patients, insurers, and office team members in a responsible, professional, and ethical manner.
Ability to function effectively in a team-oriented environment.
Ability to work independently with limited direction.
Reliability, sound judgment, and initiative.
Ability to work in a high-volume, fast-paced environment.

Responsibilities

Answer calls from patients and physician offices using exemplary customer service skills.
Accurately enter required clinical and non-clinical information into the computer database.
Review clinical data against specified medical criteria and follow established procedures for authorizing requests for further review.
Review incoming orders for completeness and determine whether the ordered procedure is covered by insurance, including whether pre-certification is warranted.
Follow up with physicians regarding orders awaiting documentation and obtain missing documentation from physician offices.
Work with patients’ insurance companies to pre-certify or authorize procedures ordered by referring physicians.
Update ordering physicians when procedures are denied and assist with scheduling peer-to-peer reviews when needed.
Contact patients when orders are complete to confirm receipt and explain that they will receive a scheduling call once insurance approval is obtained.
Monitor pre-certification status to ensure timely processing and completion.
Log orders in the appropriate authorization spreadsheet and schedule procedures once approved.
Maintain patient confidentiality in accordance with state, federal, and company regulations.
Establish effective rapport with employees, support staff, customers, clients, patients, families, and physicians.
Support departmental and corporate strategic plans and their successful implementation.
Maintain cooperative working relationships with clinics and providers.