Prior Authorization Specialist

Responsibilities

• Screen and prioritize prior-authorization and coordination-of-specialized-services requests
• Verify patient insurance and obtain authorizations through Epic and payer portals
• Process authorization requests for inpatient, outpatient, and ancillary services
• Authorize specified services under manager supervision and refer clinically complex requests for review
• Coordinate financial clearance, pre-registration, demographic and insurance verification activities
• Obtain referral authorizations and precertification numbers
• Answer ACD calls and emails from providers, patients, and departments
• Verify member eligibility and enter required information into CCMS or Facets
• Inform callers and providers about network providers, services, benefits, and authorization decisions
• Monitor and clear registration and prior-authorization work queues
• Obtain, document, and link referrals and prior authorizations to scheduled services in Epic
• Collaborate with patients, providers, physicians, practices, insurance carriers, case management, and Patient Financial Counseling
• Coordinate peer-to-peer reviews and **escalate** denied or financially uncleared accounts
• Interview patients, families, or referring physicians to obtain demographic, financial, and insurance information
• Reconcile registration and insurance information with payer records
• Refer self-pay or unresolved-insurance patients to Patient Financial Counseling
• Maintain confidentiality and comply with healthcare collection laws, regulatory policies, and organizational procedures
• Meet productivity, quality, accuracy, and turnaround-time expectations
• Participate in training, quality audits, onboarding, and process-improvement initiatives
• Report faulty systems or equipment to the appropriate support teams
• Perform other related duties as assigned

Requirements

• High school diploma or GED required
• Associate’s Degree or higher preferred
• 4-5 years of office experience in a high-volume data entry office, customer service call center, healthcare office, or hospital administration required
• Meditech experience strongly preferred
• Experience using insurance payer websites, such as Blue Cross Blue Shield and Medicare
• Customer service experience preferred
• Experience with insurance verification, prior authorization, pre-certification, and financial clearance processes
• Bilingual preferred
• Ability to process high-volume requests with a 95% or greater accuracy rate
• Ability to prioritize workload and process referrals and authorization requests within specified turnaround timeframes
• Strong oral and written communication skills
• Thorough knowledge of the financial clearance process
• Familiarity with insurance, referral authorizations, and third-party billing procedures
• Knowledge of basic medical terminology and ICD-9/CPT coding helpful
• Experience within Epic preferred
• Technical proficiency with Epic work queues and ancillary systems, including ADT/Prelude/Grand Centrale
• Microsoft Suite proficiency, specifically Excel, Word, Outlook, and Zoom
• Knowledge of medical terminology and/or coding
• Ability to maintain strict confidentiality of personal, health-sensitive, financial, and medical information
• Ability to make independent decisions under pressure
• Ability to multitask, manage complex processes, and maintain attention to detail
• Core Competencies

Demonstrates expertise in insurance verification, prior authorization, and financial clearance processes, with proficiency in Epic and Meditech systems.

Strong communication skills and the ability to manage high-volume requests while maintaining accuracy and confidentiality are essential.

• Highest-signal resume keywords
• Insurance Verification
• Prior Authorization
• Financial Clearance
• Epic Proficiency
• Customer Service Experience
• Hard Skills
• Data Entry
• Insurance Payer Websites
• ICD-9 Coding
• CPT Coding
• Referral Authorizations
• Third-Party Billing Procedures
• Medical Terminology
• High-Volume Request Processing
• Accuracy Rate of 95% or Greater
• Demographic Verification
• Soft Skills
• Strong Oral Communication
• Strong Written Communication
• Attention to Detail
• Ability to Multitask
• Independent Decision-Making

Certifications & Qualifications

• High School Diploma or GED
• Associate’s Degree or Higher Preferred
• Industry Keywords
• Healthcare
• Patient Financial Counseling
• Regulatory Policies
• Confidentiality
• Quality Audits
• Tools & Technologies
• Epic
• Meditech
• Microsoft Excel
• Microsoft Word
• Microsoft Outlook
• Microsoft Zoom
• CCMS
• Facets
• ADT/Prelude/Grand Centrale
• #J-18808-Ljbffr