Prior Auth

Job Description

Job Title: Prior Authorization Specialist 
Department: Registration

FLSA Classification: Non-Exempt – Eligible for Overtime
Employment Status: Full-Time

Location: Harrison County Community Hospital
Reports To: Registration Director

Job Summary/Objective:
The Prior Authorization Specialist in the medical clinic is responsible for obtaining prior authorizations for tests, medications, procedures, and treatments as required by insurance providers. This role ensures timely approvals, facilitates communication between patients, providers, and insurance companies, and minimizes delays in patient care. The specialist maintains accurate records, ensures compliance with insurance guidelines, and provides exceptional support to the clinical team and patients.

Essential Functions/Duties/Responsibilities:
•    Obtain prior authorizations for medications, procedures, diagnostic tests, and other services as required by insurance plans.
•    Review and submit clinical documentation to insurance providers to support the need for requested services.
•    Follow up on pending authorizations and communicate approvals, denials, or additional information requests to providers and clinical staff.
•    Work with providers and clinical teams to gather necessary documentation and ensure timely and accurate submissions.
•    Maintain accurate and organized records of all prior authorization requests and statuses.
•    Communicate with patients to provide updates regarding authorization approvals, delays, or issues.
•    Identify and resolve any discrepancies or authorization errors to avoid interruptions in patient care.
•    Educate staff on prior authorization requirements and workflows to streamline clinic processes.
•    Monitor insurance provider policies and guidelines for changes related to authorizations.
•    Collaborate with the billing department to ensure authorizations are appropriately tied to billing processes.
•    Maintain patient confidentiality in accordance with HIPAA and organizational policies.
•    Other job duties as assigned.

Skills/Abilities:
•    Strong understanding of prior authorization processes and insurance guidelines.
•    Excellent organizational and time management skills to handle multiple requests simultaneously.
•    Strong verbal and written communication skills to interact with providers, patients, and insurance representatives.
•    Proficiency in using electronic medical record (EMR) systems and prior authorization portals.
•    Attention to detail and problem-solving skills to resolve authorization issues efficiently.
•    Ability to work independently while prioritizing tasks in a fast-paced environment.
•    High level of professionalism, accuracy, and commitment to patient care.

Education, Certificates, and License:
Education:
•    High school diploma or equivalent preferred.
•    Associate degree in a healthcare-related field preferred.
Certificates:
•    Certification as a Medical Assistant (CMA) or equivalent preferred but not required.
License:
•    None required.

Experience:
•    Minimum of 1 year of experience in a medical clinic, physician office, or healthcare setting.
•    Prior experience in prior authorizations, medical billing, insurance verification, or related role preferred.
•    Experience with electronic medical record (EMR) systems and insurance portals is advantageous.

Physical Requirements:
•    Lifting: Occasionally lift or move items up to 10 pounds.
•    Mobility: Sit, stand, and move throughout the clinic environment for extended periods.
•    Dexterity: Use of hands for typing, phone operation, and handling documentation.
•    Hearing/Listening: Clear auditory ability to communicate with patients, staff, and insurance representatives.
•    Vision: Adequate visual acuity for reading screens, documents, and insurance guidelines.
________________________________________
EEOC Statement:
Harrison County Community Hospital District provides equal employment opportunities to all employees and applicants and prohibits discrimination and harassment of any type, without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity, or any other characteristic protected by law.