Medication Prior Authorization Specialist

Company Overview

Pacific Northwest Urology Specialists is dedicated to delivering personalized, high-quality urological care in a friendly and relaxed environment. As the largest and most trusted full-service urology practice in Whatcom County, our team of experienced, board-certified and eligible urologists works collaboratively to serve patients of all ages, from newborns to seniors.

Job Summary

We are seeking a detail-oriented and proactive Medication Prior Authorization Specialist to join our healthcare team. The ideal candidate will possess a strong understanding of health insurance policies, medical coding, and prior authorization processes. In this role, you will be responsible for managing insurance prior authorization requests, ensuring compliance with clinical confidentiality policies, and facilitating smooth communication between providers, insurance companies, and patients to expedite treatment approvals.

Duties

• Receive, review and process medication prior authorization (PA) requests..
• Verify patient insurance coverage, benefits, formularies and authorization requirements.
• Review clinical documentation to determine whether required information is available for submission.
• Submit prior authorization requests through payer portals, electronic systems, fax or telephone.
• Communicate with providers and clinical staff to obtain supporting documentation, medical records, diagnosis information and other required details.
• Track PA requests from initial submission through approval, denial, appeal or expiration.
• Follow up with insurance companies and PBMs regarding pending requests and missing information
• Communicate authorization decisions and next steps to providers, pharmacies and patients as appropriate.
• Identify opportunities for alternative medications, formulary options, quantity limits, step-therapy requirements or other payer-specific criteria.
• Assist with medical authorization appeals and gathering supporting documentation when required.
• Maintain accurate and timely documentation in electronical medical records and/or pharmacy systems.
• Protect patient privacy and maintain compliance with HIPAA and applicable regulations
• Meet established productivity, accuracy, turnaround time and quality standards.
• Stay current on payer policies, formularies, medication requirements, and change to prior authorization criteria.
• Escalate complete clinical insurance or authorization issues to manager or providers as appropriate.

Skills

• Strong knowledge of health insurance policies, managed care processes, and insurance verification procedures.
• Proficiency in medical terminology, CPT coding, ICD-9/ICD-10 coding standards, and medical billing practices.
• Experience with electronic health records (EHR) systems such as EMR/EHR management tools.
• Excellent organizational skills with the ability to manage multiple cases simultaneously while maintaining attention to detail.
• Effective communication skills for liaising with healthcare providers, insurance representatives, and patients.
• Familiarity with Microsoft Office suite for documentation and reporting purposes.
• Knowledge of clinical confidentiality policies such as HIPAA to ensure privacy compliance at all times.
• Prior experience in a medical office setting or healthcare environment is preferred.

Join our team as a Medication Prior Authorization Specialist where your expertise will directly contribute to providing timely access to essential treatments while supporting our commitment to exceptional patient care.

Pay: $21.50 - $27.00 per hour

Expected hours: 30.0 – 40.0 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off

Work Location: In person