Prior Authorization Specialist

JOB DESCRIPTION

Prior Authorization Specialist

Alliance Family Health Center, Inc. 

BASIC FUNCTION:

The Prior Authorization Specialist is responsible for the efficient operation and flow of tracking patient prior authorizations and associated scheduling requirements. This role works and communicates internally within the practice and with external insurance payers and specialty offices to ensure patients receive proper care as directed by the providers. The Prior Authorization Specialist is responsible for collecting, processing, and monitoring authorizations concurrent with facility guidelines. They are also responsible for verifying patient benefits and improving service delivery using established policies, procedures, and guidelines.

JOB DUTIES AND COMPETANCIES:

1. Inputs, processes, reviews, and logs authorization requests and auto-authorizations per guidelines and according to defined time and accuracy standards.

2. Requests authorization extensions or peer-to-peer reviews when necessary to ensure continuity of care.

3. Process all STAT authorizations with immediate priority to prevent delays in urgent treatment.

4. Notify patients and providers of authorization status, including approvals, denials, or pending requests.

5. Perform detailed Benefits Investigation, including verifying coverage for specific procedures, medications, and durable medical equipment (DME).

6. Secure approvals for outpatient diagnostic imaging (e.g., MRI, CT scans, PET scans).

7. Coordinate authorizations for specialist referrals and ensure all necessary clinical documentation is attached.

8. Provides administrative support as needed to maintain office flow.

9. Maintains effective communication with supervisors, providers, and clinical staff regarding insurance hurdles or delays.

10. Attend department meetings and training sessions as directed.

11. Other duties as assigned.

HEALTH CARING STANDARDS / VALUES: 

1. Greet customers, visitors, and Colleagues immediately with a smile, warm greeting, and introduction, calling them by name if possible.

2. Exceed the expected and anticipate the unexpected by asking, “Is there anything else I or a fellow Colleague can do for you?”

3. Always provide a comforting, timely, caring departure or discharge, and always say thanks for allowing us to serve.

4. Integrity, openness and fairness in all you do

5. Teamwork

6. Individual creativity

7. Innovation

8. Compassion and caring

AGE APPROPRIATE CARE:

Will provide successful services and/or interactions with the following age groups and will demonstrate the use of appropriate interventions, communication and skills to match the age and/or abilities of the patient where applicable:

A) Pediatric

B) Adolescent

C) Adult

D) Geriatric

MACHINES, TOOLS & EQUIPMENT USED:

1. Utilizes the telephone system correctly.

2. Demonstrates correct use of the computer, including appropriate software programs used by the department.

3. Demonstrates correct use of the FAX machine and copier.

4. Skilled in computer applications such as MS Word, Excel

EDUCATION, TRAINING & EXPERIENCE:

1. Medical office experience preferred.

2. Knowledge and experienced in medical terminology

3. Experience with Scheduling and Authorizations is required.

4. Demonstrated skill in computer applications (typical applications: Microsoft Office, eClinicalWorks, Availity, RadMD etc.).

5. High school graduate or equivalent

6. Experience preferred.

PHYSICAL REQUIREMENTS:

1. Able to stand/walk to various departments intermittently through a 8 hour shift.

2. Able to bend to reach items on the floor, desk level, and overhead.

3. Able to lift books and supplies weighing 25lbs. intermittently.

4. Able to see clearly (with or without lenses) and hear normal speaking tones.

5. Able to communicate verbally interpersonally and over the telephone in a clear and concise speech.

6. Able to use hands for tasks (writing, typing, etc.).

RESPONSIBLE TO:

Health Information Manager