Overview
A Prior Authorization Specialist is a professional who is responsible for obtaining prior authorizations for various medical procedures, medications, and services. This individual works in collaboration with healthcare providers, insurers, and patients to ensure that patients receive the appropriate care and treatment while managing costs and keeping up with healthcare policies.
Function
The primary role of a Prior Authorization Specialist is to manage the Prior Authorization process for diagnostic imaging, cardiac imaging, prescription medications, hospital administered IV infusions, Veterans Administration authorizations, durable medical equipment, and referral authorizations for specialty appointments. They must secure the Prior Authorization and notify the rendering party in the timeliest manner possible to ensure that patients receive the services needed with the least delay.
Job Responsibilities
- Receive and process requests for Prior Authorizations through the electronic health record (EHR) and/or via phone or fax
- Process referrals and submit medical records to insurance carriers to expedite Prior Authorization processes
- Review and approve or deny medical necessity documentation to expedite approvals and ensure appropriate follow-up
- Maintain accurate and complete records of all communications and authorizations
- Follow up on denied Prior Authorizations to obtain necessary information to appeal the decision
- Prioritize incoming authorizations by level of urgency to ensure timely access to care
- Maintain patient information in accordance with organizational policy/procedure
Requirements
- High school diploma or equivalent
- Prior experience in a clinic setting preferred
- Knowledge of insurance process and medical terminology
Qualifications and Skills
- Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee_base
- Ability to communicate through appropriate channels, use proper chain of command for patient complaints
- Ability to handle emergency situations calmly and effectively
- Must be computer literate and able to navigate through the Electronic Health Record (EHR)
- Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization
- Provide customer service in accordance to the organization’s mission
- Be courteous and respectful when interacting with patients and family members
- Maintain patient confidentiality in accordance to organization’s policy and procedure and HIPAA requirements
Working Conditions
- Regularly required to sit, use hands to finger, handle, or feel, reach with hands and arms, talk or hear
- Occasionally required to stand, walk, and lift and/or move up to 10 pounds
- Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus
- Computer work is frequent
- Good lighting and comfortable temperature of ventilation at all times
Training and Certifications
- Prior Authorization Training –National Board of Prior Authorization Specialists, a division of ACMA
- PACS is the only accredited certification program for prior authorization and payer policies recognized in the industry
- The PACS program takes 10-12 hours to complete and includes 12 modules
- The first step towards achieving the gold standard in the healthcare and life sciences industry
Conclusion
Prior Authorization Specialists play a crucial role in healthcare access, authorization process management, and patient care coordination. Their role requires a strong understanding of insurance processes, medical terminology, and excellent communication skills. With the increasing demand for healthcare services and the need for cost control, Prior Authorization Specialists will continue to be an essential part of healthcare delivery systems.
