Prior Authorization Specialist (PHRN - Registered Nurse)

We are seeking a detail-oriented and organized Prior Authorization Specialist to join our healthcare team. In this role, you will be responsible for obtaining prior authorizations for medical procedures, diagnostic tests, and medications from insurance providers. You will serve as a key liaison between healthcare providers, patients, and insurance companies to ensure timely and accurate approval of services, helping to minimize delays in patient care.

About the Role

As a Prior Authorization Specialist, your primary responsibilities include reviewing medical documentation and verifying insurance coverage to determine the need for prior authorization for procedures, tests, and prescriptions. You will submit prior authorization requests to insurance carriers, follow up on pending approvals, and ensure all documentation is complete and compliant with payer requirements. In collaboration with healthcare providers and clinical staff, you will gather necessary information to support the authorization process and communicate updates to patients regarding the status of their approvals. Additionally, you will maintain accurate records in the electronic health record (EHR) system, respond to insurance inquiries, appeal denied requests when appropriate, and stay informed on payer policy changes to help reduce authorization delays. Strong attention to detail, knowledge of insurance guidelines, and excellent communication skills are essential for success in this role.

Qualifications :

• Must possess an active PHRN license
• Experience as a Quality Auditor in Clinical Services within a healthcare BPO is preferred; alternatively, 4 to 7 years of focused experience in Clinical Authorization or Utilization Review.
• Proficient in using EPIC, MCG, or InterQual guidelines