This position is responsible for managing prior authorizations, coordinating between providers and payors, verifying clinical documentation, resolving denials, and supporting efficient, compliant access to treatments, medications, and services.
Job Functions
- Contacts insurance companies on behalf of patients and clinic to obtain prior authorizations for prescriptions, tests and procedures
- Serves as a patient advocate and functions as a liaison between the patient, provider and payor for prior authorization
- Provides information to support the medical necessity of patient medications, treatments and testing
- Communicates with physicians and their team members to obtain necessary information as well as to inform them of any special requirements by particular insurance plans
- Researches additional or alternative resources for non-covered services
- Monitors incoming orders and gathers necessary documentation to ensure pre-certification, authorization, and referral requirements are met prior to the delivery of outpatient and ancillary services
- Works with insurance companies and staff to obtain initial and ongoing authorizations for patients in advance of services
- Reviews accuracy and completeness of information requested to ensure that all supporting documents are present
- Researches, corrects, and resubmits rejected/denied insurance authorizations or peer to peer authorizations
- Conducts clinically informed review of provider orders, documentation, and medical records to determine medical necessity based on payer guidelines and evidence-based criteria
- Identifies missing, insufficient, or inconsistent clinical information and proactively obtains clarifications from providers
- Reviews denial trends and recommends clinical-focused process improvements to reduce avoidable denials
- Performs other duties as assigned.
Minimum Qualifications
- CMA or LPN
- 1 year of experience
Knowledge/Skills and Abilities
· Ability to meet and maintain the necessary background checks as aligned with position functions.
· Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above.
· Knowledge of Payer requirements and expectations regarding prior authorization
· Knowledge of pharmacy, pharmaceuticals, or healthcare business
· Familiarity with CPT/HCPCS and ICD-10
· Ability to proficiently analyze and interpret clinical criteria
· Works effectively across organization and fosters teamwork
· Demonstrated excellent customer service and communication skills - verbal, written, and listening
· Demonstrated knowledge of medical terminology
· Must demonstrate ability to work independently with analytical, problem-solving and decision- making