Prior Authorization Specialist
On-siteNaples, Florida, United States
Job Summary
Review scheduled services and patient accounts to determine whether prior authorization or precertification is required. Verify patient insurance eligibility, benefits, and authorization requirements, then obtain authorizations for procedures, diagnostic services, imaging, and medications through payer portals, telephone systems, or fax. Gather and submit all required clinical documentation, including physician notes, medical records, and test results, ensuring accurate patient, provider, diagnosis, and insurance information. Monitor pending requests, follow up with insurance companies within required timeframes, and document authorization numbers, effective dates, and approved services in appropriate systems. Communicate authorization status to scheduling, clinical, billing, and other departments, proactively resolving issues that may delay patient care. Assist with authorization denials by reviewing payer responses, coordinating peer-to-peer reviews, reconsiderations, and appeals, and tracking expiration dates for extensions. Maintain accurate records of all activity, follow payer-specific guidelines, and communicate trends or concerns to management.
Required Qualifications
- High school diploma or equivalent
- Previous healthcare, medical office, insurance, Revenue Cycle, or prior authorization experience
- Ability to sit and work at a computer for extended periods
- Ability to communicate effectively by telephone, email, and electronic systems
- Ability to perform repetitive computer and data-entry tasks
- Ability to occasionally lift or move office supplies and materials
Desired Qualifications
- Previous experience obtaining insurance authorizations
- Knowledge of medical terminology, CPT, ICD-10, and HCPCS coding
- Familiarity with commercial insurance plans, Medicare, Medicaid, HMOs, PPOs, and other managed-care plans
- Experience using insurance payer portals and electronic authorization systems
- Experience with electronic medical records (EMR) and practice management systems
- Strong computer and data-entry skills
- Excellent verbal and written communication skills
- Strong attention to detail and accuracy
- Excellent organizational and time-management skills
- Ability to manage multiple authorization requests and deadlines simultaneously
- Strong problem-solving and critical-thinking skills
- Ability to work independently while also functioning effectively as part of a team
- Professional and courteous communication with patients, payers, providers, and internal departments
- Bilingual English/Spanish
- Prior authorization and precertification processes
- Insurance eligibility and benefits verification
- Medical necessity requirements
- Payer-specific authorization guidelines
- CPT, ICD-10, and HCPCS codes
- Medical documentation requirements
- Denial prevention and resolution
- Appeals and reconsideration processes
- Medicare, Medicaid, commercial insurance, and managed-care plans
- Electronic payer portals and authorization platforms
- EMR and practice management systems
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