Job Overview
The Prior Authorization Specialist is responsible for obtaining, tracking, and documenting insurance authorizations and pre-certifications for all scheduled surgical procedures at the Ambulatory Surgery Center. This role ensures timely verification of benefits and authorization requirements to prevent claim denials, reduce revenue cycle delays, and support a seamless patient experience. The specialist serves as a critical liaison between the clinical team, surgeons' offices, and third-party payers.
As a representative of this facility, all comments, attitudes, actions, and behaviors have a direct affect on the center's image and perceptions of quality service. Interaction with patients, physicians, referral sources, guest, visitors, volunteer workers, co-workers, supervisors, vendors, etc. must be in a manner that is friendly, supportive, courteous, respectful, cooperative and professional. This behavior should promote and atmosphere of teamwork that is congruent with the centers standards and guidelines to promote positive relations.
Duties
1. Prior Authorization Acquisition
a) Initiate and obtain prior authorizations and pre-certifications for all scheduled surgical and procedural cases in a timely manner, typically 5–7 business days prior to the procedure date.
b) Verify authorization requirements for each payer and plan type, including commercial insurance, Medicare Advantage, Medicaid managed care, and Workers' Compensation.
c) Submit authorization requests via payer portals, phone, fax, and electronic data interchange (EDI) platforms.
d) Obtain peer-to-peer review support from physicians when initial authorization is denied.
2. Insurance Verification
a) Verify patient eligibility, active coverage, deductibles, co-pays, co-insurance, and out-of-pocket maximums for all scheduled cases.
b) Confirm coordination of benefits (COB) when multiple payers are involved.
c) Identify and communicate patient financial responsibility to the billing team prior to the procedure.
3. Documentation and Recordkeeping
a) Accurately document all authorization numbers, approval dates, service codes, and payer contacts in the practice management system (PMS) and/or EHR.
b) Maintain an active authorization tracking log with status updates for all pending and approved cases.
c) Ensure clinical documentation submitted to payers (operative notes, clinical letters, ICD-10/CPT code sets) is complete, accurate, and compliant.
4. Denial Management and Appeals
a) Identify and escalate initial authorization denials immediately upon receipt.
b) Prepare and submit first-level appeals with supporting clinical documentation within payer-required timelines.
c) Track denial trends and report patterns to the Revenue Cycle Manager for root-cause analysis.
5. Communication and Coordination
a) Serve as the primary point of contact for surgeons' offices, clinical staff, and scheduling regarding authorization status.
b) Notify the surgical team and patient of any authorization issues that may impact the scheduled procedure date.
c) Communicate authorization requirements and benefit details clearly to patients when applicable.
6. Regulatory and Payer Compliance
a) Maintain current knowledge of CMS guidelines, payer-specific medical policies, and coverage determination bulletins.
b) Ensure all authorization activities comply with HIPAA privacy and security requirements.
c) Adhere to ASC policies and procedures related to revenue cycle operations.
7. Reporting and Quality Improvement
a) Generate and review weekly authorization status reports to ensure no cases are scheduled without required authorization.
b) Participate in revenue cycle team meetings and process improvement initiatives.
c) Track and report key metrics including authorization turnaround time, denial rate, and appeal success rate.
Skills
- In-depth knowledge of health insurance policies, managed care processes, and insurance verification procedures
- Proficiency in medical terminology, medical coding (CPT, ICD-9/10), and medical billing practices, and UB 04 and HCFA 1500 forms.
- Strong understanding of electronic health records (EHR/EHR management) and EMR systems
- Excellent customer service skills with the ability to communicate clearly and professionally with patients, providers, and insurance representatives
- Familiarity with Microsoft Office Suite for documentation and reporting purposes
- Knowledge of clinical confidentiality policies such as HIPAA to ensure patient privacy is maintained at all times
- Ability to multitask efficiently in a fast-paced environment while maintaining attention to detail
- Data Entry, Bookkeeping, Typing, Accounting Software, Computer Knowledge, Accounting Knowledge.
- 2 years of Work Experience, College Degree and Bilingual (English/Spanish) is preferred
Join us in this rewarding role where your expertise will directly impact patient care delivery by ensuring timely access to necessary treatments. We value energetic professionals who thrive on collaboration, accuracy, and making a difference every day!
Pay: From $22.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
