Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Prior Authorization Specialist is a vital team member responsible for efficiently managing the prior authorization process to ensure seamless patient care and timely treatment. This position requires a solid understanding of medical benefits, step therapy, and authorization policies, along with exceptional organizational, communication, and problem-solving skills. • Processes prior authorizations accurately and efficiently, including reviewing step therapy, minimum authorization requirements, and payer-preferred medications. • Manages appeals and denials, escalating cases when necessary, and follows appropriate payer protocols. • Analyzes insurance policies for each case and communicates with internal teams or providers to obtain needed documentation when the case does not align with policy. • Verifies insurance benefits and determines in-network (INN) or out-of-network (OON) status across various payers and states under Intake standards. • Evaluates medical and pharmacy benefits to determine patient eligibility for treatment. • Maintains clear, professional communication with providers, patients, internal teams, and stakeholders. • Accurately documents all case-related conversations and updates within Salesforce within required timeframes. • Prioritizes personal tasks and authorizations to ensure timely completion and follow-up. • Collaborates with internal team members (e.g., PACs, clinical staff, sales) to gather or clarify case information. • Investigates and resolves complex cases using strong critical thinking and problem-solving skills. • Organizes and manages authorization workload efficiently to meet performance goals. • Follow and produce by Intake standards for accuracy and completion standards. Qualifications • Minimum 2-3 years of experience as a Medical Assistant (MA), with direct prior authorization and biologic therapy experience. • Proven ability to interpret clinical documentation and understand commercial and Medicare Advantage policies, including Local Coverage Determinations (LCDs). • Strong experience working with systems like Salesforce, WeInfuse, and AMD. • Background in a specialty field such as Rheumatology, Gastroenterology, Dermatology, Neurology, or Immunology preferred. • Excellent communication and customer service skills with both clinical teams and patients. • Highly organized and capable of managing multiple priorities in a fast-paced environment. • Strong documentation habits and time management skills. Requirements • High School diploma or equivalent required. • Certification or formal training as a Medical Assistant required. • Biologic Authorization experience required. • Must meet U.S. employment eligibility requirements. • Proficiency with EMRs, CRMs (Salesforce), and prior authorization systems. • Works comfortably in software like a PMS or EMR to track information, schedule and make notes. • Ability to meet U.S. employment and eligibility requirements. Apply tot his job