Prior Authorization and Denial Management

Role & responsibilities

• Obtain prior authorizations across all client service lines and document them in the correct location in Athena.
• Work denials end to end. Identify the denial reason, confirm root cause, correct and resubmit where documentation supports it, and appeal where it does not.
• Call payers directly. Do not close a claim as non-recoverable without first contacting the payer, confirming the reason, and asking whether benefits or contract terms changed.
• Pursue retro authorizations where a service was performed without an authorization on file.
• Support letters of medical necessity by gathering the clinical documentation the payer is asking for and coordinating with the onsite team on drafting.
• Identify and report patterns. If the same denial reason repeats, flag it to the client and adjust the authorization process to stop it at the front end.
• Respond to client questions raised in Athena chat within the same business day.

Preferred candidate profile

• athenaOne proficiency. Hands-on athenaOne experience with minimal ramp-up required. This is the client's firmest requirement. Candidates without real Athena time should not be shortlisted.
• Three or more years obtaining commercial and government prior authorizations, including payer portal submissions and phone authorizations.
• Three or more years in denial management or AR follow-up with demonstrated appeal experience on high-dollar claims.
• Working knowledge of CPT, ICD-10, modifiers, and how documentation supports level of service.
• Comfortable calling US payers and holding a line of questioning until the reason is confirmed. Persistence is being explicitly tested for.
• Clear written English. All client communication happens in writing inside Athena.
• Available for a full shift on Central Time.
• HIPAA trained. Will work only under Staffingly's signed BAA and secured infrastructure.

PREFERRED QUALIFICATIONS

• Prior authorization experience with infusion therapy or specialty drugs, including buy and bill workflows.
• Neurology, physical therapy, or diagnostic imaging authorization background.
• Experience with medical necessity appeals for EEG, NCV, EMG or advanced imaging.
• Clinical background (RN, PharmD, MBBS or equivalent) is a plus for medical necessity work.

DENIAL TYPES THIS ROLE WILL WORK

• No authorization on file or authorization mismatch
• Bundled or inclusive service denials
• Medical necessity denials, most often on CT, EEG and NCV
• Coding denials involving ICD-10 selection or modifiers
• Level of service not supported by submitted documentation
• Frequency limits and benefit maximum reached

PERFORMANCE EXPECTATIONS

• Authorizations obtained before date of service, with the approval documented in Athena in the agreed location.
• No claim written off without a documented payer call and a stated reason.
• Client questions in Athena chat answered same business day.
• Weekly denial trend summary shared with the client, including repeat root causes and the fix applied.
• Quality and productivity reviewed by the assigned Team Lead and by VP, RCM.