About the role
Role Overview
We are seeking a proactive and organized Prior Authorization Specialist to support U.S.-based healthcare providers with insurance authorization processes. The ideal candidate has hands-on experience verifying insurance requirements, submitting prior authorization requests, coordinating with insurance companies, and tracking pending approvals to help ensure patients receive timely access to care.
Key Responsibilities:
1. Prior Authorization Processing: Submit and manage prior authorization requests for medical procedures, medications, treatments, diagnostic tests, and other healthcare services.
2. Insurance Verification: Verify patients’ insurance coverage, benefits, eligibility, and authorization requirements.
3. Documentation Management: Gather, review, and submit supporting clinical documentation, medical records, and other required information to insurance providers.
4. Insurance Coordination: Communicate with insurance companies, healthcare providers, pharmacies, and clinical teams regarding authorization requirements and status updates.
5. Follow-Up and Status Tracking: Monitor pending requests, follow up on outstanding authorizations, and ensure submissions are processed within required timelines.
6. Denial Management: Identify reasons for denied or delayed authorizations and assist with resubmissions, appeals, and requests for additional information.
7. Electronic Health Records (EHR): Document authorization details, communication, and approval statuses accurately in the appropriate EHR or practice management system.
8. Patient and Provider Communication: Provide timely updates to relevant team members regarding authorization approvals, denials, and outstanding requirements.
9. Compliance and Confidentiality: Maintain accurate records and handle protected health information (PHI) in accordance with HIPAA and applicable healthcare privacy requirements.
Requirements:
1. At least 1 year of prior authorization experience in a U.S. healthcare setting.
2. Experience working with U.S. health insurance companies and understanding authorization requirements.
3. Knowledge of insurance eligibility, benefits verification, medical necessity documentation, and authorization workflows.
4. Familiarity with commercial insurance plans and government programs such as Medicare and Medicaid is an advantage.
5. Experience using electronic health records (EHRs), practice management systems, and insurance payer portals.
6. Strong written and verbal communication skills, particularly when communicating with insurance representatives and healthcare teams.
7. Excellent organizational skills and the ability to manage multiple requests, follow-ups, and deadlines.
8. Ability to work independently in a remote environment while maintaining accuracy and productivity.
9. Reliable internet connection and a suitable home-based work setup.
10. Willingness to work in alignment with U.S. business hours.
Preferred Qualifications
1. Experience supporting U.S.-based medical practices, clinics, hospitals, or specialty providers.
2. Familiarity with payer portals and electronic prior authorization platforms.
3. Experience with medication prior authorizations, specialty medications, or procedure-based authorizations.
4. Knowledge of denial follow-ups, appeals, and authorization expiration tracking.
5. Experience with healthcare systems such as Athenahealth, eClinicalWorks, AdvancedMD, or other EHR and practice management platforms.
Ideal Candidate Profile:
The ideal candidate is proactive, organized, and persistent in following up on authorization requests. They can communicate professionally with insurance companies, understand the importance of accurate documentation, and help minimize treatment delays by ensuring authorization requests are submitted and monitored efficiently.