DUTIES AND RESPONSIBILITIES: Essential Job Functions:
1. Reviews the Master Tracking Log and initiates prior authorization requests in a timely and accurate manner.
2. Gathers required documentation, including clinical notes, insurance information, laboratory results when required, and payer-specific forms.
3. Submits prior authorizations to insurance carriers through appropriate payer-approved methods.
4. Documents submission details in the patient chart and Master Tracking Log.
5. Coordinates medication delivery for office-administered medications when applicable.
6. Communicates authorization updates to patients, providers, and appropriate staff.
7. Maintains complete and accurate documentation according to office workflow and documentation standards.
8. Works daily from the Master Tracking Log to review pending authorizations and identify items requiring follow-up.
9. Follows up with insurance companies, specialty pharmacies, and infusion providers regarding pending requests.
10. Determines authorization outcomes and updates the patient chart and Master Tracking Log.
11. Uploads and files approval or denial documentation in the patient chart.
12. Notifies providers of denials and clarifies whether an appeal, medication change, or resubmission is requested.
13. Sends complete appeal packets to the Appeals Coordinator when applicable.
14. Escalates urgent denials, payer delays, or authorization barriers to providers and supervisory personnel.
15. Provides cross-coverage support within the biologic prior authorization workflow to help fill gaps between initiation, follow-up, tracking, and appeals responsibilities.
16. Reviews the Master Tracking Log for aging items, incomplete entries, missing documentation, delayed payer responses, pending specialty pharmacy needs, and authorization cases requiring additional follow-up.
17. Assists other PAs with gathering missing clinical documentation, insurance information, payer forms, laboratory results, and other supporting information needed for submission or resubmission.
18. Assists other PAS with follow-up on pending authorizations, payer requests for additional information, specialty pharmacy updates, approval documentation, denial documentation, and tracking updates.
19. Helps prepare denial and appeal support documentation by locating approval or denial letters, chart notes, previous submissions, payer correspondence, and other documents needed by the Appeals Coordinator.
20. Monitors cases that are delayed, at risk of missing expected turnaround times, or require additional communication and escalates concerns to the appropriate coordinator, provider, Appeals Coordinator, Practice Manager, or designated supervisory personnel.
21. Assists with communication between patients, providers, clinical staff, insurance carriers, specialty pharmacies, and infusion facilities when coordination is needed to move the authorization or appeal process forward.
22. Performs quality review of authorization-related documentation for completeness, consistency, and accuracy in the patient chart and Master Tracking Log.
23. Supports workflow continuity during staff absences, high-volume periods, urgent authorization needs, and other situations where additional coordination is needed.
KNOWLEDGE, SKILLS AND ABILITIES:
1. Knowledge of medical office workflows, insurance authorization processes, payer requirements, and healthcare documentation standards.
2. Ability to communicate professionally with patients, providers, clinical staff, insurance representatives, pharmacies, and infusion facilities.
3. Ability to maintain accurate records and update tracking tools consistently, including the Master Tracking Log.
4. Ability to prioritize pending authorizations, follow-up needs, denials, appeals, and urgent access-to-care concerns.
5. Ability to support cross-coverage needs and recognize gaps that may delay biologic medication access.
6. Ability to maintain confidentiality of patient information and follow HIPAA and office policies.
MINIMUM QUALIFICATIONS/REQUIREMENTS:
Education/Experience Requirements:
1. High school diploma or GED required.
2. Previous experience in a medical office, insurance authorization, specialty pharmacy, referral, infusion, biologic medication coordination, or related healthcare setting preferred.
3. Computer competency and ability to use electronic medical record systems, payer portals, and tracking tools required or must be obtained through training.
EOE
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Health insurance
- Life insurance
- Paid time off
- Parental leave
- Vision insurance
Work Location: In person
