PRIOR AUTHORIZATION SPECIALIST

New Horizon Medical Solutions•Las Vegas, NV

1d•$40,000 - $52,000•Onsite

About The Position

The Prior Authorization Specialist is responsible for completing insurance verification requests (IVRs), validating patient eligibility and benefits, and preparing, submitting, and tracking prior authorization requests through payer portals and Medicare Administrative Contractors. The role manages daily verification queues in internal tracking systems, documents approvals and denials with complete supporting detail, communicates outcomes to client offices under HIPAA-compliant standards, and coordinates escalations so that time-sensitive dates of service are never missed. This position is central to preventing downstream claim denials and supporting a clean revenue cycle.

Requirements

High school diploma or GED required.
2+ years of experience in prior authorization, insurance verification, or medical billing/front-office operations in a healthcare setting.
Working knowledge of Medicare Part A/Part B eligibility rules, managed care plans, MSP, and commercial payer benefit structures.
Familiarity with medical terminology and CPT/ICD-10/HCPCS coding as used in authorization requests.
Proficiency with payer portals, EHR systems, and Microsoft Office (Word, Excel, Outlook).
High level of accuracy and attention to detail in verification and documentation.
Strong prioritization and time management; ability to triage STAT and date-of-service-driven work.
Clear, professional written and verbal communication with client offices and payers.
Sound judgment on when to escalate and strict adherence to HIPAA confidentiality standards.

Nice To Haves

Prior Authorization Certified Specialist (PACS) certification through the ACMA — the recognized industry-standard credential for authorization professionals.
Medical billing/administrative certification such as AAPC CPB or NHA CMAA/CBCS.
Experience with Smartsheet, NetSuite, and MAC portal workflows (Noridian/Novitas).
Experience with wound care, DME, or medical device authorizations is a plus but not required.

Responsibilities

Review daily verification queues and work new and pending IVR requests according to priority indicators, dates of service, and STAT flags.
Verify Medicare eligibility and benefits through MAC portals (e.g., Noridian, including Novitas-jurisdiction patients) and commercial coverage through payer portals (e.g., Availity, UnitedHealthcare Provider Portal).
Confirm coverage determinants including Part A/Part B status, SNF status, managed care enrollment, hospice election, and Medicare Secondary Payer (MSP) situations.
Complete standardized IVR forms accurately and document verification outcomes as Approved or Denied with clear supporting rationale.
Prepare, submit, and track prior authorization requests with complete clinical documentation, per payer and LCD/NCD requirements.
Follow up on pending authorizations through resolution; document authorization numbers, effective dates, and approved units/visits.
Identify missing information and coordinate with client offices to obtain documentation needed to complete verification or authorization.
Send standardized, HIPAA-compliant status communications (approved / denied / additional information needed) to client contacts with required internal stakeholders copied.
Maintain complete, audit-ready documentation in internal tracking systems (e.g., Smartsheet) and support downstream quote/order creation (e.g., NetSuite) for approved requests.
Escalate account exceptions, outreach issues, and workflow blockers to the appropriate team lead or client liaison without delay.