Acute Prior Authorization Specialist

California Specialty Pharmacy,LLC; California (MO); On-site; USD 52,000 - 78,000; Full time

Job summary

California Specialty Pharmacy, LLC is seeking an Acute Prior Authorization Specialist to ensure timely and accurate approvals for acute medical services. You will review clinical documentation, verify benefits, and navigate payer requirements to expedite care while ensuring compliance.

The role collaborates with healthcare providers, insurers, and patients to reduce delays in acute care, maintain records, and support clinical and administrative teams.

Qualifications

• Minimum 1–2 years in prior authorization, medical billing, or healthcare administration.
• Strong knowledge of insurance plans and reimbursement processes.
• Proficiency with electronic health records (EHR) and prior authorization tools.
• Excellent communication skills, written and verbal, with diverse stakeholders.

Responsibilities

• Review and process prior authorization requests for acute medical services per payer guidelines.
• Request and clarify clinical documentation from providers as needed.
• Verify patient insurance coverage and benefits to determine authorization requirements.
• Collaborate with insurers to resolve denials, appeals, and inquiries.

Skills

Prior Authorization

Healthcare Administration

EHR Proficiency

Education

High school diploma

Tools

EHR Systems

Prior Authorization Software

Job description

The Acute Prior Authorization Specialist plays a critical role in the healthcare delivery process by ensuring timely and accurate authorization of acute medical services. This position involves collaborating closely with healthcare providers, insurance companies, and patients to facilitate the approval of necessary treatments and procedures. The specialist is responsible for reviewing clinical documentation, verifying insurance benefits, and navigating complex payer requirements to expedite care without compromising compliance. By efficiently managing prior authorization requests, this role directly impacts patient outcomes and satisfaction by reducing delays in receiving acute care services. Ultimately, the Acute Prior Authorization Specialist serves as a vital liaison that supports both clinical teams and administrative operations within the healthcare system.

Minimum Qualifications:

• High school diploma or equivalent.
• Minimum of 1-2 years experience in prior authorization, medical billing, or healthcare administration.
• Strong knowledge of medical terminology, insurance plans, and healthcare reimbursement processes.
• Proficiency with electronic health records (EHR) systems and prior authorization software tools.
• Excellent communication skills, both verbal and written, with the ability to interact professionally with diverse stakeholders.

Preferred Qualifications:

• Certification as a Certified Prior Authorization Professional (CPAP) or similar credential.
• Experience working within acute care settings such as hospitals or emergency departments.
• Familiarity with Medicare, Medicaid, and commercial insurance policies and procedures.
• Demonstrated ability to manage multiple priorities in a fast-paced environment.
• Advanced computer skills including Microsoft Office Suite and data management applications.

Responsibilities:

• Review and process prior authorization requests for acute medical services in accordance with payer guidelines and clinical criteria.
• Communicate effectively with healthcare providers to obtain necessary clinical documentation and clarify treatment plans.
• Verify patient insurance coverage and benefits to determine authorization requirements and limitations.
• Collaborate with insurance companies to resolve denials, appeals, and inquiries related to prior authorization requests.
• Maintain accurate records of all authorization activities and ensure compliance with regulatory and organizational policies.
• Provide timely updates to clinical teams and patients regarding the status of authorization requests.
• Identify opportunities to improve prior authorization workflows and contribute to process optimization initiatives.

Skills:

The Acute Prior Authorization Specialist utilizes strong analytical skills daily to interpret clinical documentation and insurance policies, ensuring accurate and efficient authorization decisions. Effective communication skills are essential for liaising between healthcare providers, insurance representatives, and patients to gather information and provide updates. Attention to detail is critical when reviewing medical records and entering data into electronic systems to maintain compliance and reduce errors. Time management and organizational skills enable the specialist to handle multiple authorization requests simultaneously while meeting strict deadlines. Additionally, problem-solving abilities are frequently applied to resolve authorization denials and navigate complex payer requirements, contributing to smoother patient care coordination.