Prior Authorization Specialist

MML US Inc•San Diego, CA

7h•$75,000 - $85,000•Onsite

About The Position

The Prior Authorization Specialist plays a critical role in helping patients gain timely access to Mainstay Medical therapy by navigating the insurance authorization process with accuracy, urgency, and persistence. Working closely with Case Managers, and internal reimbursement and market access partners, the Prior Authorization Specialist helps ensure that each patient’s case is complete, well-supported, and positioned for efficient payer review. It is a specialized patient-access position that requires strong reimbursement knowledge, disciplined follow-through, attention to detail, and the ability to resolve complex barriers. This is not a transactional paperwork role. The Prior Authorization Specialist serves as an internal subject-matter resource, helping move patients through the authorization process while reducing avoidable delays, preventable denials, and administrative burden on physician offices and field sales teams.

Requirements

Bachelors degree and a minimum of 2 years related experience, or an advanced degree without experience, or equivalent work experience.
Experience in a medical office, hospital setting, or payer with coding and prior authorization experience or utilization review.
Knowledge of health insurance industry practices and functions.
Experience with Medicare, Medicaid, Tricare, Workers Compensation, and Commercial Insurance.
Superior oral and written communication skills.
Demonstrates excellent organization skills with attention to detail.
Proficient in Microsoft Office, including Microsoft Word, Outlook, Excel, and PowerPoint.
Experience working with platforms such as Salesforce, Availity, eFax systems, and other basic database management programs.
Problem solver and capable to find solutions to challenges or process impediments.
Maintains a caring, empathetic, and patient-centric approach in all interactions.

Responsibilities

Manage the prior authorization process as requested by the health care provider for assigned patients from initial submission through approval, denial resolution, or escalation.
Maintain consistent accountability until the authorization process has been resolved.
Contribute to the development of standardized resources, templates, and best practices.
Communicate with case management to ensure that submissions align with payer policies, medical necessity criteria, and documentation standards.
Submit prior authorization requests accurately and promptly through designated payer portals, systems, or communication channels.
Monitor submissions closely and respond quickly to requests for additional information.
Review denial notices carefully in partnership with case management to determine the underlying issue and appropriate next step.
Maintain working knowledge of payer requirements, authorization pathways, coverage criteria, and documentation expectations.
Recognize differences across commercial payers, government programs, and regional reimbursement environments.
Share payer and operational insights to strengthen strategy and foster a culture of accountability, responsiveness, and continuous improvement.
Ensure all documentation and communication meet regulatory, privacy, and company requirements while protecting patient confidentiality.
Use approved systems and workflows consistently to support audit readiness and disciplined process adherence.
Escalate complex or high-risk cases appropriately and involve the right resources at the right time.
Maintain accurate, timely documentation of payer interactions, submissions, authorization status, and follow-up activities.
Partner and communicate closely with Case Managers to provide clear visibility into authorization status, barriers, and next-step priorities.
Maintain accurate status information within designated systems.
Collaborate cross-functionally to resolve cases and support patient access.
Escalate complex or high-risk cases appropriately while identifying trends and recommending process improvements.