The Senior Medical Prior Authorization Specialist is a pivotal role within our healthcare administration team, responsible for overseeing the prior authorization process for medical services and treatments. This position requires an experienced professional who can navigate complex insurance requirements, communicate effectively with healthcare providers, and ensure timely and accurate authorization of services to optimize patient care and operational efficiency.
Key Responsibilities:
- Prior Authorization Management:
- Review and process prior authorization requests for medical procedures, medications, and services.
- Ensure compliance with insurance guidelines and policies.
- Maintain up-to-date knowledge of insurance plan benefits, requirements, and industry changes.
- Case Review and Documentation:
- Analyze clinical information and medical records to support authorization decisions.
- Document all interactions, decisions, and outcomes in the electronic health record (EHR) system.
- Coordinate with healthcare providers to obtain necessary documentation and additional information as required.
- Communication and Coordination:
- Serve as a liaison between healthcare providers, insurance companies, and patients.
- Educate and guide healthcare providers and staff on the prior authorization process and requirements.
- Resolve issues related to denied or delayed authorizations, working collaboratively with all stakeholders to find solutions.
- Quality Assurance and Improvement:
- Monitor and audit prior authorization processes to identify areas for improvement.
- Develop and implement strategies to enhance the efficiency and accuracy of authorization procedures.
- Participate in training and development programs for team members.
- Compliance and Reporting:
- Ensure all prior authorization activities comply with federal, state, and local regulations, as well as organizational policies.
- Prepare and present regular reports on authorization metrics, trends, and performance to management.
Qualifications:
- Education and Experience:
- Bachelor's degree in healthcare administration, nursing, or a related field (preferred).
- Minimum of 5 years of experience in medical prior authorization, healthcare insurance, or a related field.
- Certification in medical billing and coding or a related area (preferred).
- Skills and Competencies:
- In-depth knowledge of medical terminology, coding (ICD-10, CPT), and insurance processes.
- Strong analytical skills with the ability to review and interpret clinical documentation.
- Excellent communication and interpersonal skills.
- Proficiency in using EHR systems, prior authorization software, and MS Office Suite.
- Ability to work independently, manage multiple tasks, and meet deadlines in a fast-paced environment.
Work Environment:
- Location: Upper Marlboro, MD
- Schedule: Full-time, Monday to Friday
Benefits:
- Competitive salary
- Health, dental, and vision insurance
- Retirement savings plan with employer match
- Paid time off and holidays
- Professional development opportunities
Job Type: Full-time
Pay: $24.00 - $30.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Weekly day range:
Experience:
- Insurance verification: 5 years (Required)
Language:
Ability to Commute:
- Upper Marlboro, MD 20774 (Required)
Ability to Relocate:
- Upper Marlboro, MD 20774: Relocate before starting work (Required)
Work Location: In person