Prior Authorization Specialist - Certified

Responsibilities

• The Authorization Representative will need to cover authorizations for all services (CT, MRI, echo, surgery, minor procedures, heart monitor, PFTs, sleep studies, IP, Observations, Swing Bed, ED, VA), excluding STAT requests.
• Initial request and follow up required along with reporting of authorization status.

Prior Authorization and Eligibility

• Initiate, submit, and track prior authorization requests across commercial and managed care payers.
• Verify patient eligibility and benefits prior to authorization submission and confirm coverage, plan requirements, authorization thresholds, deductibles, copays, and other applicable benefit information.
• Ensure authorization requests contain complete and accurate demographic, clinical, and supporting documentation.
• Monitor pending authorization requests through payer portals and direct payer communication and proactively follow up through resolution.
• Document authorization numbers, approved services, CPT codes, effective dates, expiration dates, session or visit limits, and other payer requirements.

Concurrent Reviews and Authorization Management

• Manage concurrent review, continued stay, and authorization renewal requirements for ongoing services.
• Track authorization limits and expiration dates and initiate renewals before existing authorizations are exhausted.
• Maintain accurate authorization records and communicate pending or expiring authorizations to appropriate operational and clinical teams.
• Help prevent gaps in authorization that could result in delayed services or lost reimbursement.

Denials and Appeals

• Review authorization-related denials and determine whether the cause is clinical, administrative, eligibility-related, or procedural.
• Coordinate appropriate corrective action and appeal activity within payer deadlines.
• Prepare clear and accurate appeal documentation and coordinate with clinical and operational teams to obtain supporting information when required.
• Track appeals through resolution and maintain complete documentation of outcomes.
• Identify recurring denial trends and escalate systemic payer or process issues.

Payer and Revenue Cycle Coordination

• Serve as a resource for payer authorization requirements, policies, portals, and workflows.
• Maintain current knowledge of payer requirements and communicate material changes to appropriate teams.
• Coordinate with billing, intake, clinical, credentialing, and contracting teams to resolve authorization-related reimbursement barriers.
• Support single-case agreements, out-of-network authorization requests, and other payer authorization functions as needed.
• Assist with payer audits and utilization management reviews by providing complete authorization records and supporting documentation.

Documentation and Reporting

• Maintain accurate and timely authorization activity within applicable EHR, practice management, and tracking systems.
• Maintain payer authorization matrices and workflow documentation, including submission requirements, turnaround times, authorization limits, and renewal requirements.
• Track authorization performance, including approval rates, denial rates, appeal outcomes, turnaround times, and outstanding requests.
• Identify trends and recommend workflow improvements that strengthen revenue integrity and reduce preventable denials.
• Maintain compliance with HIPAA and all applicable privacy and confidentiality requirements.

Qualifications

• Previous experience in healthcare Revenue Cycle Management, with direct responsibility for prior authorization, eligibility and benefit verification, payer follow-up, or related revenue cycle functions.
• Strong understanding of prior authorization requirements, payer timelines, submission processes, and authorization tracking.
• Strong understanding of the differences between eligibility, benefits, authorization, and medical necessity requirements.
• Experience working with commercial and managed care payers.
• Experience using payer portals such as Availity, NaviNet, and payer-specific platforms.
• Working knowledge of CPT codes and their relationship to payer authorization requirements.
• Experience managing denials and authorization appeals.
• Experience with EHR, practice management, or other healthcare revenue cycle systems.

Requirements

• CPC required.
• PACS preferred.
• Excellent attention to detail and analytical skills.
• Strong organizational skills with the ability to manage multiple authorization queues and deadlines simultaneously.
• Strong written and verbal communication skills and the ability to work effectively with payer representatives and internal operational teams.
• Working knowledge of HIPAA and healthcare privacy requirements.
• US based candidates eligible for employment without sponsorship.