Job Description

Job Description

Job Description

Summary: The Prior Authorization Specialist plays a critical role in ensuring timely and accurate authorization of services, medications, and procedures. This position supports both clinical staff and patients by navigating payer requirements and removing access barriers. The ideal candidate is organized, detail-oriented, and understands the urgency of specialty care approvals, especially in a nephrology setting.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Minimum Qualifications

• Medical Certification (e.g., CMA, RMA).
• High school diploma or GED required.
• Strong knowledge of insurance plans, prior authorization processes, and medical terminology required.
• Experience with EHR systems and payer portals strongly preferred.
• Nephrology or specialty care experience is a plus but not required
• Working knowledge of nephrology, terminology, procedures, and medications is strongly preferred.
• Experience using electronic health records (EHR), payer portals, and prior auth platforms.
• Understanding of insurance plans, benefits verification, and medical necessity criteria.
• Knowledge of Medical Terminology, CPT codes and ICD-10 codes
• Knowledge of VA and Tricare authorizations
• Minimum of 1 to 2 years of clinical experience

Knowledge, Skills, and Abilities

• Professional and respectful communication with patients, coworkers, and external partners.
• Strong organizational skills and attention to detail.
• Ability to work in a fast-paced environment, prioritize tasks, and meet deadlines.
• Maintains professional and positive communication with payers, clients, and other staff.
• Maintains confidentiality of all information regarding clients, families, and employees
• Maintains knowledge regarding new procedures, medications, and health information systems.
• Self-directed and motivated
• Ability to prioritize tasks.
• Excellent communications skills verbally and non-verbal
• Basic computer skills such as Outlook, Word, and Excel

Essential Functions (%)

• Verify insurance and determine auth requirements for nephrology services, labs, and prescriptions – 20%
• Submit prior auth requests via payer portals, fax, or phone – 15%
• Track and follow up on pending authorizations to ensure timely approvals – 10%
• Collaborate with providers and staff to gather necessary clinical documentation – 10%
• Communicate auth status, denials, or requests to providers and patients – 10%
• Appeal denied authorizations with medical necessity support. Peer to Peer interaction – 15%
• Document authorizations in the EHR and maintain records for compliance – 10%
• Support audits, monitor timelines, and assist in process improvement – 5%
• All other duties as assigned – 5%

Physical Demands

• Hearing, visual acuity, depth perception, balancing, handling, and talking.
• Reaching, grabbing, holding – fine motor skills.
• Extended periods in a stationary or standing position.
• Repetitive motion such as entering data into computer-based programs and frequent phone use.
• Lift or move up to 25 pounds. Employees are expected to use appropriate ergonomics and tolls such as hand carts for heavier loads.

Work Environment

Work is normally performed in a typical interior/office work environment. The noise level is usually moderate. While performing the duties of this job, the employee is regularly required to stand and talk or hear. Work days Monday to Friday, 8 a.m. to 5 p.m.

This position may be eligible for remote or hybrid work based on business needs, department needs, job duties, performance, and management approval. Remote work is not guaranteed and is not a condition of employment. The organization reserves the right to approve, deny, modify, or end remote work arrangements at any time.

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