Prior Authorization Specialist at PIEDMONT ARTHRITIS – Greenville, South Carolina

Prior Authorization Specialist

Department: Patient Access / Billing & Reimbursement

Reports To: Office Manager

Status: Full-Time / Non-Exempt

The Prior Authorization Specialist is responsible for ensuring patients have timely access to prescribed medications and procedures by managing the end-to-end authorization process. This role acts as the vital link between the clinical team, the patient, and the payer to secure coverage and minimize financial risk for the practice.

• Benefit Verification: Determine if prescribed therapies (specifically biologics and specialty infusions) fall under the Medical Benefit (Part B) or Pharmacy Benefit (Part D).
• Submission Management: Initiate and track prior authorization requests via payer portals, fax, or phone, ensuring all required ICD-10, HCPCS, and CPT codes are accurate.
• Clinical Coordination: Collaborate with the clinical staff to gather necessary documentation, including chart notes, lab results, and treatment history to support Medical Necessity.
• Denial & Appeals: Review denied claims and authorizations; assist the physician in drafting Letters of Medical Necessity (LMN) and submitting formal appeals within payer-mandated timelines.
• Patient Communication: Educate patients on their coverage status, potential out-of-pocket costs, and the status of their pending authorizations.
• Financial Advocacy: Identify and enroll eligible patients in Patient Assistance Programs (PAPs) or co-pay card programs to help manage their financial liability.
• Workflow Integration: Update and maintain the Practice Management System and EMR to ensure the billing team has the necessary authorization numbers to submit "clean claims."

• Education: High School Diploma required; Associate’s or Bachelor’s degree in Healthcare Administration or a related field preferred.
• Experience: 1–3 years of experience in medical billing, patient access, or prior authorization, specifically with biologic therapies.
• Technical Skills: Proficiency in Electronic Medical Records (EMR) and Practice Management Systems.
• Knowledge Base: Deep understanding of medical terminology, the Buy-and-Bill procurement model, and the difference between Commercial and Government (Medicare/Medicaid) payers.
• Certification: Certified Professional Coder (CPC) or Certified Revenue Cycle Representative (CRCR) is a plus.

• Attention to Detail: Precision in verifying NDC numbers and authorization dates to prevent non-payment.
• Communication: Ability to navigate complex conversations with insurance adjusters while remaining empathetic toward patients.
• Persistence: A "problem-solver" mindset to navigate payer "red tape" and follow up on pending requests daily.
• Organization: Capacity to manage a high volume of active cases while meeting strict deadlines for treatment starts.

• Fast-paced clinical or administrative office setting.
• Requires frequent use of phone, computer, and fax.