Position Summary:
The Prior Authorization Specialist is a vital team member responsible for efficiently managing the prior authorization process to ensure seamless patient care and timely treatment. This position requires a solid understanding of medical benefits, step therapy, and authorization policies, along with exceptional organizational, communication, and problem-solving skills. The role involves consistent collaboration with providers, clinical teams, local PACs, and sales representatives, requiring outstanding professionalism and multitasking abilities.
· The Specialist will manage a caseload of at least 30 active authorizations and must skillfully navigate systems such as Salesforce, WeInfuse, and AMD to track and update case progress, send communications, and meet critical deadlines. This role is key to maintaining operational efficiency and directly contributes to Pure’s standard of excellence and patient satisfaction.
Key Responsibilities
· Processes prior authorizations accurately and efficiently, including reviewing step therapy, minimum authorization requirements, and payer-preferred medications.
· Manages appeals and denials, escalating cases when necessary, and follows appropriate payer protocols.
· Analyzes insurance policies for each case and communicates with internal teams or providers to obtain needed documentation when the case does not align with policy.
· Verifies insurance benefits and determines in-network (INN) or out-of-network (OON) status across various payers and states under Intake standards.
· Evaluates medical and pharmacy benefits to determine patient eligibility for treatment.
· Maintains clear, professional communication with providers, patients, internal teams, and stakeholders.
· Accurately documents all case-related conversations and updates within Salesforce within required timeframes.
· Prioritizes personal tasks and authorizations to ensure timely completion and follow-up.
· Collaborates with internal team members (e.g., PACs, clinical staff, sales) to gather or clarify case information.
· Investigates and resolves complex cases using strong critical thinking and problem-solving skills.
· Organizes and manages authorization workload efficiently to meet performance goals.
· Follow and produce by Intake standards for accuracy and completion standards.
Required Knowledge and Skills
· Minimum 2-3 years of experience as a Medical Assistant (MA), with direct prior authorization and biologic therapy experience.
· Proven ability to interpret clinical documentation and understand commercial and Medicare Advantage policies, including Local Coverage Determinations (LCDs).
· Strong experience working with systems like Salesforce, WeInfuse, and AMD.
· Background in a specialty field such as Rheumatology, Gastroenterology, Dermatology, Neurology, or Immunology preferred.