Prior Authorization

General Summary

The Prior Authorization Specialist coordinates and secures insurance authorization for medications, in-office injections, and imaging when needed to support timely patient care. This role involves reviewing payer requirements, gathering appropriate clinical documentation, and communicating with insurance companies, pharmacies, and internal staff to facilitate authorization approvals. The ideal candidate demonstrates strong time management, attention to detail, integrity, and the ability to manage multiple requests while maintaining organization and professionalism in a high-volume environment. 

Key Responsibilities 

• Complete authorization submissions through electronic platforms, payer portals, and telephone communications with insurance representatives when required. 

• Review patient charts to obtain relevant clinical documentation needed to support authorization requests 

• Communicate professionally with insurance companies, pharmacies, patients, and internal staff regarding authorization requirements and status updates. 

• Track and update prior authorization requests and outcomes using internal tracking tools and insurance portals to ensure timely processing and follow-up. 

• Demonstrate accountability for assigned authorization requests by monitoring status and following up with payers when necessary.  

• Actively monitor PA Pool and EHR inbox communications to ensure timely response to authorization requests and related inquiries. 

• Ensure all prior authorization submissions and supporting documentation accurately reflect the patient’s medical record and comply with payer requirements. 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; stoop, kneel, crouch, or crawl; and talk or hear.  The employee must occasionally lift and/or move more than 45 pounds.

• Familiarity with medical terminology and working knowledge of medical coding systems (CPT, ICD-10) relevant to prior authorization requests. 

• Strong organizational and time management skills, with the ability to prioritize urgent requests and meet deadlines in a high-volume environment. 

• Excellent written and verbal communication skills when interacting with patients, insurance representatives, pharmacies, and internal clinical staff. 

• Ability to work both independently and collaboratively within a team while managing multiple tasks simultaneously. 

• Demonstrates integrity, professionalism, and ethical decision-making when handling patient information and submitting prior authorization requests. 

• HS Diploma or GED  required.