Prior Authorization Specialist

Gebbs Healthcare Solutions Inc

28d • $26 - $26

About The Position

The Prior Authorization Specialist handles authorization requests across a broad range of services, including CT, MRI, echocardiography, surgery, minor procedures, heart monitoring, pulmonary function tests, sleep studies, inpatient care, observations, swing-bed care, emergency department services, and VA services. STAT requests are excluded. The role includes initiating requests, following up, and reporting authorization status.

The position verifies eligibility and benefits, submits and tracks requests with commercial and managed care payers, monitors pending requests, manages concurrent reviews and renewals, and documents authorization requirements and outcomes. It also addresses authorization-related denials and appeals, coordinates with payer and internal revenue-cycle teams, maintains accurate records and workflow documentation, reports performance trends, and helps improve processes while maintaining HIPAA and privacy compliance.

Requirements

• Previous experience in healthcare Revenue Cycle Management, with direct responsibility for prior authorization, eligibility and benefit verification, payer follow-up, or related revenue-cycle functions.
• Strong understanding of prior authorization requirements, payer timelines, submission processes, and authorization tracking.
• Strong understanding of the differences between eligibility, benefits, authorization, and medical necessity requirements.
• Experience working with commercial and managed care payers.
• Experience using payer portals such as Availity, NaviNet, and payer-specific platforms.
• Working knowledge of CPT codes and their relationship to payer authorization requirements.
• Experience managing denials and authorization appeals.
• Experience with EHR, practice management, or other healthcare revenue-cycle systems.
• Excellent attention to detail and analytical skills.
• Strong organizational skills and ability to manage multiple authorization queues and deadlines simultaneously.
• Strong written and verbal communication skills and ability to work effectively with payer representatives and internal operational teams.
• Working knowledge of HIPAA and healthcare privacy requirements.
• Must be a US-based candidate eligible for employment without sponsorship.

Responsibilities

• Cover authorizations for applicable services, excluding STAT requests; initiate requests, follow up, and report authorization status.
• Initiate, submit, and track prior authorization requests across commercial and managed care payers.
• Verify patient eligibility and benefits and confirm coverage, plan requirements, authorization thresholds, deductibles, copays, and other applicable benefit information.
• Ensure authorization requests contain complete and accurate demographic, clinical, and supporting documentation.
• Monitor pending requests through payer portals and direct payer communication, and proactively follow up through resolution.
• Document authorization numbers, approved services, CPT codes, effective and expiration dates, session or visit limits, and other payer requirements.
• Manage concurrent reviews, continued-stay requirements, and authorization renewals for ongoing services.
• Track authorization limits and expiration dates and initiate renewals before authorizations are exhausted.
• Maintain accurate authorization records and communicate pending or expiring authorizations to operational and clinical teams.
• Help prevent authorization gaps that could delay services or reduce reimbursement.
• Review authorization-related denials and determine whether causes are clinical, administrative, eligibility-related, or procedural.
• Coordinate corrective actions and appeals within payer deadlines; prepare appeal documentation and obtain supporting information from clinical and operational teams as needed.
• Track appeals through resolution, document outcomes, identify recurring denial trends, and escalate systemic payer or process issues.
• Serve as a resource for payer authorization requirements, policies, portals, and workflows; maintain knowledge of payer requirements and communicate material changes.
• Coordinate with billing, intake, clinical, credentialing, and contracting teams to resolve authorization-related reimbursement barriers.
• Support single-case agreements, out-of-network authorization requests, payer audits, and utilization management reviews as needed.
• Maintain timely authorization activity in applicable EHR, practice management, and tracking systems.
• Maintain payer authorization matrices and workflow documentation, including submission requirements, turnaround times, authorization limits, and renewal requirements.
• Track authorization performance, including approval and denial rates, appeal outcomes, turnaround times, and outstanding requests.
• Identify trends and recommend workflow improvements that strengthen revenue integrity and reduce preventable denials.
• Maintain compliance with HIPAA and applicable privacy and confidentiality requirements.

What This Job Offers

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