Jobs

Description

Job Title: Prior Authorization Specialist

Department: Revenue Cycle / Billing

Reports To: Sr. Director of Billing and Reimbursement

Location: Onsite Preferred – Work From Home

Position Summary

• The Prior Authorization Specialist is responsible for the timely and accurate submission of prior authorizations for Category I molecular pathology testing.
• The role requires reviewing clinical documentation, applying payer-specific medical necessity criteria, and ensuring alignment between CPT and ICD-10 coding.
• This position supports revenue cycle performance by minimizing authorization-related denials and delays.

Core Responsibilities

• Submit and manage high-volume prior authorizations (~75-100 per day)
• Review and interpret medical records, clinical documentation, and lab requisitions
• Responsible for reviewing and submitting authorization level appeals
• Data entry, correct insurance assignment to patient accounts, insurance eligibility verification
• Review/update demographics and patient information for accuracy
• Ensure appropriate linkage between CPT codes and ICD-10 diagnoses
• Apply payer policies across Commercial, Medicare Advantage, and Medicaid payers
• Utilize payer portals, automated tools, and internal systems to process authorizations
• Monitor and track authorization statuses and complete required follow-up actions
• Collaborate with internal billing teams to resolve authorization discrepancies
• Maintain full compliance with HIPAA regulations and payer guidelines

Minimum Qualifications

2–4 years of relevant experience in:

• Prior authorization processing
• Laboratory billing
• Healthcare revenue cycle
• High school diploma required; some college preferred

Working knowledge of:

• CPT coding (molecular preferred)
• ICD-10 coding and medical necessity guidelines
• Ability to interpret clinical documentation and testing requests
• Strong knowledge and experience with Microsoft Excel as well as Word and Outlook, general office equipment, and ten-key by touch
• Ability to easily adapt to increased business demands

Skills & Competencies

• Strong analytical and critical thinking skills
• High level of attention to detail and accuracy
• Ability to interpret and apply payer policies
• Effective internal communication skills
• Ability to work in a high-volume, production-driven environment
• Strong organizational and multi-tasking capabilities
• Self-starter, ability to work independently.
• Excellent communication and customer service skills; cooperative, work collaboratively and treat others in respectful, professional and supportive manner.
• Desire to learn and apply learned concepts to various situations.

Tools & Systems

• Salesforce
• Glidian
• XIFIN
• Payer portals and automated authorization platforms
• Microsoft Excel

Performance Expectations

• Meet or exceed daily productivity targets (authorization volume)
• Maintain high accuracy and data integrity
• Ensure timely submission and follow-up
• Adhere to payer requirements and compliance standards