Position Title

Prior Authorization Specialist / Prior Authorization Coordinator

Department

Prior Authorization Department

Job Summary

The Prior Authorization Specialist is responsible for obtaining insurance authorizations and approvals for medical services, treatments, medications, procedures, and equipment. This role works closely with physicians, clinical staff, insurance companies, and patients to ensure timely approvals and accurate documentation while maintaining compliance with payer guidelines and company policies.

Essential Duties and Responsibilities

Submit prior authorization requests to insurance providers for medical services, medications, procedures, and treatments

Verify patient insurance eligibility and benefits

Review clinical documentation to ensure authorization requirements are met

Communicate with physicians, nurses, pharmacies, and other departments regarding authorization status and additional documentation needs

Follow up with insurance companies on pending, denied, or incomplete authorizations

Process authorization renewals and extensions as needed

Document all authorization activities accurately in the EMR/EHR system

Maintain knowledge of insurance payer guidelines, Medicare, Medicaid, and commercial insurance requirements

Assist with appeals and denial management when authorizations are denied

Ensure all approvals are obtained prior to scheduled services when required

Maintain confidentiality of patient information in compliance with HIPAA regulations

Provide excellent customer service to patients and internal staff

Qualifications

High school diploma or equivalent required; associate degree preferred

Minimum of 1–2 years of experience in healthcare, medical billing, insurance verification, or prior authorization preferred

Knowledge of medical terminology, CPT, ICD-10, and HCPCS coding preferred

Experience with EMR/EHR systems and insurance portals

Strong organizational and multitasking skills

Excellent communication and problem-solving abilities

Ability to work independently and in a fast-paced environment

Proficiency in Microsoft Office applications

Preferred Experience

Experience in Home Health, Hospice, Specialty Pharmacy, or Medical Office settings

Familiarity with Medicare, Medi-Cal/Medicaid, and commercial payer authorization processes

Physical Requirements

Prolonged periods of sitting and computer work

Ability to communicate effectively by phone and email

Occasional lifting of office materials up to 15 pounds

Work Environment

Office or healthcare setting

Standard business hours with occasional overtime depending on authorization volume

Skills

Attention to detail

Time management

Insurance verification and authorization processing

Data entry accuracy

Customer service

Team collaboration