Authorization Specialist

Position Summary:

The Prior Authorization Specialist is responsible for obtaining timely and accurate prior authorizations for medical procedures, imaging, surgeries, and medications ordered by providers. This role ensures compliance with insurance requirements, reduces claim denials, and supports the clinic’s revenue cycle operations. The specialist collaborates closely with providers, clinical staff, patients, and insurance companies to facilitate high-quality patient care with minimal administrative delay.

Key Responsibilities:

Verify insurance eligibility and benefit coverage for patients scheduled for diagnostic testing, surgeries, procedures, and medications.

Obtain prior authorizations from commercial and government insurance plans as required by payor guidelines.

Accurately complete and submit authorization requests with all necessary documentation (e.g., clinical notes, CPT/ICD-10 codes, supporting records).

Track the status of outstanding authorizations and follow up until approvals are received.

Communicate authorization status and any delays or denials to providers, patients, and the scheduling or billing teams.

Collaborate with clinical staff to collect additional documentation or clarification when needed.

Maintain detailed and up-to-date records in the electronic medical record (EMR) and practice management system.

Educate patients on their insurance requirements, pre-certification responsibilities, and financial responsibilities as needed.

Identify trends in denials or delays and escalate concerns to the clinic manager or billing department for resolution.

Stay up to date on insurance payor policies, requirements, and changes in authorization protocols.

Qualifications:

Required:

High school diploma or equivalent.

Minimum of 1 year of experience in medical prior authorization and insurance verification, preferably in a specialty clinic.

Strong understanding of CPT, ICD-10, and HCPCS coding.

Excellent organizational and time-management skills.

Ability to communicate effectively and professionally with internal teams and external parties.

Proficient with EMR systems and Microsoft Office (Word, Outlook, Excel).

Preferred:

Experience with prior authorizations for specialty medications and/or biologics used in ENT.

Familiarity with common payors and their web portals (e.g., Availity, Navinet).

Medical Assistant or Certified Professional Coder (CPC) credentials are a plus.

Work Environment:

Office/clinical setting.

Frequent use of computer and phone.

Fast-paced with deadlines and time-sensitive tasks.