Prior Authorization Specialist

CLS Health PLLC•Webster, TX

About The Position

CLS Health is hiring an experienced genetic testing authorization professional to run the front end of its in-house molecular genetics laboratory program. This revenue-cycle position is responsible for securing coverage for genetic and molecular testing and applying knowledge of Medicare (MolDX), Texas Medicaid, commercial payers, and laboratory benefit management programs to hereditary cancer, carrier screening, prenatal, pharmacogenomic, and somatic tumor testing. It is not a clinical role. The specialist verifies benefits, reviews orders against payer criteria, submits and tracks prior authorizations, communicates patient financial responsibility, and works with physician offices to ensure orders are complete. As the program grows, the role will help build the EMR intake workflow, train office staff, and supervise intake coordinators and in-office navigators. Performance expectations include verifying benefits within one business day, submitting authorizations within two business days of receiving complete orders, keeping a documented next action and due date for every open request, and ensuring tests are not performed without required authorization.

Requirements

At least 2 years of prior authorization or benefits verification experience specifically for genetic or molecular testing, at a genetics laboratory, molecular diagnostics company, academic genetics program, or payer utilization management vendor.
Working knowledge of genetic testing coverage policies across Medicare/MolDX, Texas Medicaid and its MCOs, and commercial payers.
Working knowledge of laboratory benefit management programs such as Carelon, eviCore, and Avalon.
Experience with molecular pathology CPT coding (81xxx and PLA codes), DEX Z-Code registration, and medical necessity documentation for genetic tests.
Experience handling peer-to-peer reviews, appeals, and ABN and cost estimate conversations for genetic testing.
Ability to work directly and effectively with physicians and office staff.
High school diploma or GED.

Nice To Haves

Experience at a national genetic testing laboratory, such as Natera, Myriad, Invitae, GeneDx, or Ambry, or at a genetics-focused billing company.
Experience building intake or authorization workflows in an EMR; eClinicalWorks experience is a plus.
Lead or supervisory experience.
Associate or bachelor's degree, or a coding or revenue-cycle certification.

Responsibilities

Review genetic test orders from CLS offices for completeness, including diagnosis, indication, family history, consent, and specimen requirements.
Verify benefits for every order and review requests against payer medical policies and test-specific criteria.
Return incomplete orders to the ordering office the same day, documenting what is missing.
Submit and track prior authorizations through payer portals and utilization management vendors such as Carelon and eviCore.
Coordinate peer-to-peer reviews and appeals with ordering physicians as needed.
Obtain test registration codes, such as DEX Z-Codes, when required by payers.
Prepare patient cost estimates and Advance Beneficiary Notices (ABNs) for non-covered tests before specimen collection.
Maintain references of coverage criteria by test and payer, including Medicare, Texas Medicaid and its MCOs, BCBSTX, UnitedHealthcare, Aetna, Cigna, and Humana.
Build and maintain the EMR intake workflow in partnership with IT and the Laboratory Manager.
Train office staff on ordering and documentation requirements.
Supervise intake coordinators and in-office genetics navigators as the team grows.
Report weekly on order volume, pending authorizations, approvals, denials, turnaround times, and cancellations.
Verify benefits within one business day of receiving an order.
Submit prior authorizations within two business days of receiving a complete order.
Document a next action and due date on every open request.
Ensure no test is performed without required authorization.