Prior Authorization Specialist
About The Position
The Prior Authorization Specialist coordinates medication and service prior authorizations, insurance eligibility checks, and patient assistance efforts to help patients obtain access to prescribed medications and services. The role works with insurance carriers, pharmacies, providers, patients, and medication assistance programs to obtain approvals, identify financial assistance opportunities, and support timely access to necessary medications and care. The specialist reviews service orders and clinical information, determines authorization requirements, submits supporting documentation, communicates approvals or denials, and accurately records authorization information in computer systems. The position also participates in denial reviews with Patient Financial Services and Credit/Collection Specialists, assists with benefit and coverage inquiries, and completes continuing education on third-party authorization requirements. The position is part time, at 0.5–0.7 FTE (40–56 hours bi-weekly), with a day shift, and is located at the legal address in Litchfield, Minnesota.
Requirements
- Associate degree or equivalent from a two-year college or technical school, or an approved equivalent combination of education and experience.
- Six months to one year of related experience and/or training, or an approved equivalent combination of education and experience.
- Basic computer and word-processing skills.
- Ability to work with multiple phone lines.
- Basic medical terminology and patient scheduling knowledge.
- Excellent communication and customer service skills.
- Ability to incorporate AIDET into professional practice.
- Knowledge of patient confidentiality and HIPAA requirements for protecting patient information from unauthorized access, use, or disclosure.
- Ability to respond quickly and decisively to emergencies and participate in shelter-in-place and disaster response protocols.
- Ability to work with interdisciplinary teams and communicate effectively with patients, families, and healthcare providers.
- Accurate data-entry skills.
- Proficiency with Microsoft Office Suite, secure messaging applications, collaborative tools such as Microsoft Teams or Google Workspace, Paycom, and applicable information systems and EHR tools.
- Ability to apply logical problem-solving and decision-making, analyze data and scenarios, evaluate approaches, and work independently with limited supervision.
- Ability to adapt communication for diverse audiences, write professional materials, present information, and coordinate messages and care across departments.
- Ability to perform basic mathematical calculations and interpret graphs, visual data, clinical measurements, and data trends.
- Ability to meet the physical demands of rural hospital and clinic work, including during emergency situations and disaster protocols.
Nice To Haves
- Familiarity with the EPIC electronic medical record system.
- Previous experience in a prior authorization role in a healthcare system.
- Previous pharmacy technician experience.
Responsibilities
- Review service orders to determine whether prior authorization is required.
- Check insurance eligibility and identify the applicable third-party payor authorization requirements.
- Compare clinical data, ICD-10-CM codes, and CPT codes with medical policies to determine medical necessity and follow procedures to authorize or refer requests for further review.
- Coordinate authorizations for provider-ordered procedures and testing for managed care patients.
- Obtain clinical documentation supporting medical necessity and authorization requirements.
- Notify relevant parties of precertification numbers and file completed precertification requests according to policy.
- Communicate prior authorization approvals or denials to patients and ordering providers’ clinics.
- Enter required prior authorization and reference information accurately into computer databases.
- Assist departments or patients with benefit information and insurance coverage inquiries.
- Prepare forms required by third-party payors for treatment authorization requests.
- Submit prior authorization documents to third-party payors in a timely and efficient manner.
- Review denials with Patient Financial Services when authorization is incomplete or incorrect.
- Complete continuing education on third-party authorization requirements through websites and online learning modules.
- Maintain patient confidentiality and follow applicable compliance, safety, attendance, training, and organizational requirements.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Part-time
Education Level
Associate degree
