A medical prior authorization specialist obtains approval from insurance companies for requested medical services and medications. Key responsibilities include gathering patient and insurance information, submitting requests, tracking their status, and communicating with patients and providers about coverage issues and denials. The role requires attention to detail, strong communication skills, and knowledge of medical terminology and insurance requirements.

Qualifications

• Education: A high school diploma is required.
• Experience: Previous experience in insurance authorization is preferred.
• Skills:
  • Knowledge of medical terminology and insurance requirements.
  • Strong attention to detail.
  • Excellent communication and interpersonal skills, both written and verbal.
  • Proficiency with computers and specialized software systems.
  • Knowledge of Portals: PEAR, Availity, UHC, UMR, Tricare, Evicore, Carelon, Resmed. Care Orchestrator, CoverMyMeds, ASPN, SureScripts is a must!
• Process authorization requests: Initiate and complete prior authorization requests for medical services, procedures, and prescriptions.
• Gather information: Collect and verify patient demographic, clinical, and insurance information needed to meet reimbursement and approval requirements.
• Communicate with stakeholders: Contact insurance companies, referring physicians, and patients to gather information, clarify coverage, and resolve issues.
• Track and monitor: Maintain accurate records of all communications and track the status of requests and appeals. Monitor schedules for add-on patients to ensure they have the necessary authorization.
• Handle denials and appeals: Follow up on denied requests and work to ensure services are approved.
• Ensure compliance: Verify that services are authorized within the required timeframes and that the process complies with insurance and regulatory requirements.

Work environment

• Primarily desk work with frequent phone and computer use.
• Often involves working in a team with other medical staff, such as Providers and Medical Assistants.
• May involve handling a high volume of calls.