Clinical Appeals & Prior Authorization Specialist

University of California - Irvine Health; Orange (CA); On-site; USD 95,000 - 125,000; Full time

Job summary

University of California, Irvine Health is seeking a PAL Clinical Specialist to support the prior authorization and utilization management workflow. The role emphasizes appeals, clinical judgment, and timely submissions to payers.

Responsibilities include processing urgent to retrospective requests, reviewing documentation, and coordinating with internal teams and health plans to resolve gaps. Strong communication and an active Pharmacist license are essential.

Qualifications

• Must have current knowledge of drug references, Joint Commission requirements, and regulatory standards.
• Must demonstrate customer service skills appropriate to the job.
• Excellent written and verbal communication skills in English.
• CA Board of Pharmacy Registered Pharmacist licensure in good standing.

Responsibilities

• Process urgent, routine, pre-service, and retrospective prior authorization requests with accuracy and timeliness.
• Review documentation, analyze requests, and enter prior authorization data for claims adjudication.
• Communicate with internal departments, providers, and health plans to obtain missing information.
• Support the authorization workflow from intake through resolution to deliver high-quality patient care.

Skills

Regulatory knowledge

Customer service

Written & verbal communication

Education

Doctor of Pharmacy

Job description

University of California, Irvine Health is seeking a PAL Clinical Specialist to support the prior authorization and utilization management workflow. The role emphasizes appeals, clinical judgment, and timely submissions to payers.

Responsibilities include processing urgent to retrospective requests, reviewing documentation, and coordinating with internal teams and health plans to resolve gaps. Strong communication and an active Pharmacist license are essential.