PRIOR AUTHORIZATION SPECIALIST

NAVAJO HEALTH FOUNDATION - SAGE MEMORIAL HOSPITAL, INC.•Ganado, AZ

5d•Onsite

About The Position

The Prior Authorization Specialist is responsible for verifying insurance coverage, securing prior authorizations, and ensuring medical necessity requirements are met for all services provided at Sage Memorial Hospital. This role supports timely patient care and accurate reimbursement by coordinating with providers, coders, Health Information Management, and insurance payers to obtain required clinical documentation and coding. The Specialist maintains compliance with payer guidelines, monitors authorization trends, and contributes to the organization’s mission and core values through accuracy, communication, and consistent workflow execution. This list of duties and responsibilities is illustrative only of the task performed by this position and is not all-inclusive.

Requirements

High School Diploma or General Equivalency Diploma (GED).
One to two years of progressive work experience in clerical support, patient registration, or insurance verification in a hospital or medical office setting.
Maintain confidentiality and comply with HIPAA regulations.
Basic understanding of commercial insurance, Medicare, Medicare Advantage Plans, Medicaid/AHCCCS, and payer authorization requirements.
Must successfully pass all Employee Health Program requirements and pass a background investigation.
Ability to communicate well in both English and Navajo.
Strong verbal and written communication skills, including the ability to communicate effectively with internal and external customers.
Ability to maintain professional, respectful, and compassionate attitude.
Ability to work efficiently, tactfully, and with consideration for patient needs.
Proficient computer skills and ability to operate standard office equipment.
Ability to perform job duties with minimal supervision.
Ability to manage multiple tasks, prioritize workload, and maintain accuracy.
Knowledge of basic medical terminology, insurance processes, and prior authorization workflows.
Understanding of clinical documentation types such as discharge summaries, lab results, and imaging reports.
Familiarity with MEDITECH Expanse or similar electronic health record systems.

Responsibilities

Understand payer policies, authorization requirements, and required timeframes, ensuring compliance with all governmental regulations, including healthcare billing standards, HIPAA, TJC, EMTALA, and Sage Memorial Hospital policies and procedures.
Verify patient demographics and confirm primary, secondary, and tertiary insurance coverage.
Obtain prior authorizations for inpatient admissions, outpatient services, clinical procedures, and surgical procedures.
Request CPT and diagnosis codes from coders when clarification or additional coding is required for authorization submission.
Document authorization approvals, reference numbers, and status updates in all required systems.
Review daily schedules to identify patients requiring insurance verification or prior authorization.
Ensure all required clinical documentation is complete, accurate, and submitted to payers for review.
Collaborate with Health Information Management to obtain any clinical documentation requested by insurance payers, including discharge summaries, lab results, imaging reports, and other required records, ensuring timely submission of required records.
Follow up with insurance companies to confirm receipt of documentation and monitor authorization progress.
Coordinate with providers to address authorization denials and assist with appeals, including Peer-to-Peer requests.
Notify management of changes, trends, or issues related to authorization requirements or payer processes.
Research and correct inaccurate insurance information in Meditech Expanse.
Refer uninsured and underinsured patients to the Patient Benefits Coordinator or assist with AHCCCS applications when appropriate.
Complete daily productivity worksheets and maintain accurate work logs.
Assist Admissions & Registration staff as assigned by management.
Attend discharge planning meetings when requested.
Perform additional duties, special projects, or assignments as needed.