Prior Authorization Specialist

The Prior Authorization Specialist is responsible for obtaining prior authorizations for all required procedures and maintaining accurate and timely record-keeping of all related documents and actions. 

KNOWLEDGE, SKILLS, & ABILITIES:  The requirements listed below are representative of the knowledge, skills and/or abilities required.

Education: High School Diploma or Equivalent

Experience: 2 years’ experience in healthcare or prior authorizations

Certifications & Licenses: N/A

Technology Applications: Knowledge of electronic medical records and practice management systems.  Proficient in Microsoft Applications.

PHYSICAL AND MENTAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job responsibilities.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit for extended periods of time; use hands to finger, handle or fell objects, tools, or controls; reach with hands and arms; climb stairs; balance, stoop, kneel, bend, crouch or crawl; talk or hear; taste or smell.  The employee must occasionally lift, push, pull and/or move up to 20 pounds.  Repetitive motion of upper body required for extended use of computer.  Required specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT AND TRAVEL REQUIREMENTS:

Works in well-lit, ventilated and climate-controlled office environment with routine office equipment; some equipment has moving mechanical parts.

Noise level in the work environment is typical for an office and/or medical clinic environment.

ESSENTIAL FUNCTIONS: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.

• Communicates with payors via phone/fax/ePA to obtain Prior Authorization for prescribed medications and/or services.
• Reviews EMR and PA Software to identify medications requiring Prior Authorization.
• Responds to outstanding prior authorization requests.
• Maintains records of medical policies and responds to staff questions regarding payor medical policies.
• Supports patients taking high risk and biologic medications and coordinates renewals and routine screenings.
• Maintains accurate and timely record-keeping of all electronic medical records and actions taken.
• Maintains prior authorization tracking spreadsheet including data entry and reporting.
• Ensures timely processing and communicates authorization status with physicians and their teams
• Predicts payor decisions and advises physicians when additional supporting documentation is recommended or required.
• Appeals authorization denials as directed by physicians.
• Anticipates and processes renewals for expiring authorizations.
• Screens and processes refill requests as appropriate.
• Maintains knowledge of manufacturer assistance programs and communicates with drug vendors and sales representatives as appropriate.
• Regular and reliable attendance.
• Perform other duties as assigned.