Prior Authorization Specialist Job Description for Resume

Updated on: June 25, 2022
Prior Authorization Specialist Job Description

A prior authorization specialist is an individual who is highly skilled in ensuring that patients receive the medication that requires pre-authorization from insurance carriers.

They receive prescriptions, address and rectify rejected claims, and conduct necessary third-party authorization requests.

Working as a prior authorization specialist means that you will need a high school diploma or a GED at the very least.

Since there is a lot of “talking” to do, it is imperative that a person working in this position is a great communicator, with exceptional writing and verbal skills.

A prior authorization specialist’s workday is usually full of appointments and telephone calls, which is why it is important that he or she works well in a multitasking role.

The ability to project a professional image, strong knowledge of regulatory standards and compliance requirements, working knowledge of medical business office procedures and basic accounting and detailed understanding of ICD-9 and CPT are important for an individual wanting to work as a prior authorization specialist.

In addition to this, one needs to possess deep insight into reimbursement and claims procedures if this is the work that one wants to take up.

So if you have some experience working in a medical billing office, medical setting, or insurance company, this may be the right job for you. Here is what you will be doing:

Duties for Prior Authorization Specialist Resume

• Interview patients to determine how they can be assisted in receiving authorizations for their medication and procedures.

• Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.

• Develop and implement prior authorization workflow, policies, and procedures.

• Collaborate with other departments to assist in obtaining pre-authorizations in a cross-functional manner.

• Review the accuracy and completeness of the information requested and ensure that all supporting documents are present.

• Receive requests for pre-authorizations and ensure that they are properly and closely monitored.

• Consult with supervisor or nurse manager to obtain clearance that treatment regimen is considered a medical necessity.

• Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.

• Manage correspondence with insurance companies, physicians, specialists, and patients as required.

• Look through denials and submit appeals in a bid to get them approved by insurance companies.

• Create patients’ records and accounts and ensure that pre-authorization information is properly updated in them.

• Secure patients’ demographics and medical information by using great discretion and ensuring that all procedures are in sync with HIPPA compliance and regulation.