Job Description
Overview We are seeking a detail-oriented and experienced Prior Authorization Specialist to join our Home Infusion Pharmacy team. This role is vital in managing the authorization process for complex medical treatments, ensuring timely approval from insurance providers to facilitate seamless patient care. The ideal candidate will have a strong understanding of managed care, medical coding, and healthcare documentation, with excellent organizational skills and a commitment to maintaining patient confidentiality in compliance with HIPAA regulations.
Responsibilities • Initiate, submit, and track prior authorizations for home infusion therapies (OPAT, biologics, IVIG, TPN, hydration, specialty injectables) • Verify insurance coverage and payer authorization requirements (medical vs. pharmacy benefit) • Partner with intake and billing teams to ensure clean handoffs and accurate reimbursementMaintain compliance with HIPAA, payer contracts, and accreditation standards (ACHC / URAC) • Coordinate with hospitals, discharge planners, physician offices, and infusion nurses to obtain required clinical documentation.
• Follow up with payers to ensure timely approvals and on-time start of care • Manage authorization denials and support appeal and peer-to-peer processes • Accurately document all activity in pharmacy or intake systems • Review and process prior authorization requests for home infusion therapies, ensuring all necessary documentation is complete and accurate. • Communicate effectively with insurance companies, healthcare providers, and patients to obtain necessary approvals. • Maintain detailed records of authorization statuses, correspondence, and related documentation in accordance with medical records management standards.
• Utilize CPT coding, ICD-9, ICD-10, and ICD coding knowledge to accurately document procedures and diagnoses. • Ensure compliance with HIPAA regulations when handling sensitive patient information. • Collaborate with medical office staff and other healthcare professionals to facilitate efficient authorization workflows. • Stay updated on insurance policies, managed care guidelines, and relevant healthcare regulations affecting authorization processes. Requirements • Proven experience in managed care, medical office administration, or a related healthcare setting.
• Strong knowledge of medical terminology, medical coding (CPT, ICD-9, ICD-10), and medical records management. • Familiarity with insurance verification processes and prior authorization procedures. • Experience working within HIPAA guidelines to protect patient confidentiality. • Office experience preferred; dental office experience is a plus but not required. • Excellent communication skills for effective interaction with insurance companies, healthcare providers, and patients. • Ability to manage multiple priorities efficiently in a fast-paced environment.
This position offers an opportunity to contribute significantly to patient care coordination within a dynamic home infusion pharmacy setting while utilizing your healthcare expertise in a supportive team environment. Job Types: Part-time, Contract Pay: $23.04 - $27.74 per hour Expected hours: 8 – 10 per week Work Location:
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