GENERAL STATEMENT OF DUTIES:
We are seeking a highly organized and detail-oriented Medical Prior Authorization Specialist to join our outpatient clinic team. The ideal candidate will have a strong background in healthcare administration, particularly in handling prior authorizations for medical procedures, tests, and treatments. This role requires efficient communication skills, analytical thinking, and the ability to navigate insurance requirements to ensure timely approvals for patient care.
ESSENTIAL FUNCTIONS:
- Review and process prior authorization requests for medical procedures, tests, medications, and treatments according to insurance guidelines and clinic protocols.
- Verify patient insurance coverage and eligibility for requested procedures or treatments. Communicate with insurance companies to obtain necessary authorization and resolve any coverage issues.
- Maintain accurate records of prior authorization requests, approvals, denials, and appeals. Document all communication with insurance companies and healthcare providers regarding authorization status.
- Communicate with patients regarding prior authorization requirements, status updates, and any financial responsibilities associated with their care. Provide assistance and guidance to patients in navigating insurance coverage and appeals processes.
- Collaborate with healthcare providers, nurses, and administrative staff to ensure timely submission and processing of prior authorization requests. Communicate effectively with other departments to coordinate patient care and ensure compliance with insurance requirements.
- Assist in the preparation and submission of appeals for denied prior authorization requests. Gather necessary documentation and information to support the appeal process and advocate for patients' medical needs.
- Stay updated on changes in insurance policies, regulations, and industry trends related to prior authorization processes. Identify opportunities for process improvements and efficiency enhancements in prior authorization management.
QUALIFICATIONS
- High school diploma required, Associates degree preferred
- Detail-oriented with strong organizational and time management skills
- Excellent communication skills, both verbal and written, with the ability to interact professionally with patients, healthcare providers and staff, and insurance representatives
- Minimum of 2 years of experience in prior authorization management in a healthcare setting, preferably in an outpatient clinic or medical office
- Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment
- Familiar with medical billing processes, and revenue cycle management is a plus
CMU is an AA/EO institution, providing equal opportunity to all persons, including minorities, females, veterans, and individuals with disabilities.
