Medical Insurance Prior Authorization Specialist

Socket.dev; Auburn (AL); On-site; USD 42,000 - 64,000; Full time

Job summary

Lee Obstetrics and Gynecology in Auburn, AL, seeks a detail-oriented Medical Insurance Prior Authorization Specialist to manage OB/GYN prior authorizations, coordinate with providers and billing, and ensure timely, accurate authorization submissions.

The ideal candidate has experience with medical insurance, prior authorization, medical billing, and revenue-cycle management, plus familiarity with CPT/ ICD-10 coding and payer portals, in a fast-paced practice setting.

Qualifications

• High school diploma or equivalent required.
• Previous experience in medical insurance, prior authorization, medical billing, referrals, or revenue cycle management preferred.
• OBGYN or specialty-practice experience strongly preferred.
• Knowledge of medical terminology required.
• Familiarity with CPT and ICD-10 coding preferred.
• Knowledge of commercial insurance, Medicare, Medicaid, and managed-care plans preferred.
• Experience using insurance payer portals preferred.
• Experience with electronic medical records and practice-management systems preferred.

Responsibilities

• Verify patient insurance eligibility and benefits when necessary.
• Determine whether OBGYN services and procedures require prior authorization.
• Review insurance plans for authorization requirements and payer-specific guidelines.
• Obtain and review necessary clinical documentation from providers and clinical staff.
• Submit prior authorization requests through payer portals, fax, telephone, and any other required methods.
• Obtain authorizations for obstetric and gynecologic procedures, surgeries, diagnostic testing, fertility-related services when applicable, in-office procedures, and other services per plan.
• Track all pending authorization requests and follow up with insurance companies in a timely manner.
• Record authorization numbers, approval dates, expiration dates, approved services, units, and other pertinent information.
• Document authorization information accurately in the patient’s account and EMR.
• Communicate authorization status with providers, nurses, surgery schedulers, billing staff, and patients.
• Notify staff if an authorization is denied, delayed, or requires additional information.
• Request additional documentation from clinical staff when required by the insurer.
• Assist with denials, reconsiderations, appeals, and peer-to-peer requests.
• Monitor expiration dates and obtain extensions or new authorizations as needed.
• Ensure approved services match correct procedure, diagnosis, provider, facility, and date of service.

Skills

Insurance knowledge

Prior authorization

OBGYN knowledge

Medical terminology

Organization

Attention to detail

Education

High school diploma

Tools

EMR systems

Practice-management systems

Job description

Lee Obstetrics and Gynecology is committed to our mission of providing quality, attentive, responsive care for the women of Lee County and the surrounding area. To put the patient's health and well-being first and promote women's health in all that we do. We are seeking a highly organized, detail-oriented Medical Insurance Prior Authorization Specialist to join our OBGYN practice.This position is responsible for managing the priorauthorization process for obstetric and gynecologic services, procedures, diagnostic testing, and surgical services. The Prior Authorization Specialist will work closely with providers, surgery scheduling, billing staff, patients, and insurance companies to ensure required authorizations are obtained accurately and within the appropriate timeframe.The ideal candidate is knowledgeable about health insurance requirements, comfortable communicating with insurance companies, and able to manage multiple time-sensitive requests while maintaining a high level of accuracy. Hours are Monday – Thursday 7:45 am – 5:00pm CT, Friday 7:45am – 5:00pm CT in our Auburn, Alabama office

Essential Duties & Responsibilities

• Verify patient insurance eligibility and benefits when necessary.
• Determine whether OBGYN services and procedures require prior authorization.
• Review insurance plans for authorization requirements and payer-specific guidelines.
• Obtain and review necessary clinical documentation from providers and clinical staff.
• Submit prior authorization requests through payer portals, fax, telephone, and any other required methods.
• Obtain authorizations for services including, but not limited to: Obstetric and gynecologic procedures
• Surgical procedures
• Diagnostic testing
• Infertility-related services when applicable
• In-office procedures
• Other services designated by the patient’s insurance plan
• Track all pending authorization requests and follow up with insurance companies in a timely manner.
• Record authorization numbers, approval dates, expiration dates, approved services, units, and other pertinent information.
• Ensure authorization information is accurately documented in the patient’s account and/or electronic medical record.
• Communicate authorization status with providers, nurses, surgery schedulers, billing staff, and patients as appropriate.
• Notify appropriate staff immediately when an authorization is denied, delayed, or requires additional clinical information.
• Request additional documentation from clinical staff when required by the insurance company.
• Assist with insurance denials, reconsiderations, appeals, and peer-to-peer requests related to prior authorization.
• Monitor authorization expiration dates and obtain extensions or new authorizations when necessary.
• Ensure approved services correspond with the correct procedure, diagnosis, provider, facility, and date of service when applicable.
• Identify authorization-related issues that could result in claim denials or delays in patient care.
• Maintain accurate and organized authorization records.
• Maintain confidentiality and comply with HIPAA and practice policies.
• Stay current with changes to insurance plans, payer requirements, authorization procedures, and OBGYN services.
• Perform other billing and revenue-cycle duties as assigned.

OBGYN-Specific Responsibilities

• Gynecology Office procedures
• Ultrasounds and diagnostic testing
• Colposcopy and related procedures
• Endometrial procedures
• Hysteroscopy D&C procedures
• Ablation procedures
• Incontinence procedures
• Pelvic floor procedures
• Gynecologic surgeries
• Other procedures requiring payer authorization

Qualifications

• High school diploma or equivalent required.
• Previous experience in medical insurance, prior authorization, medical billing, referrals, or revenue cycle management preferred.
• OBGYN or specialty-practice experience strongly preferred.
• Knowledge of medical terminology required.
• Familiarity with CPT and ICD-10 coding preferred.
• Knowledge of commercial insurance, Medicare, Medicaid, and managed-care plans preferred.
• Experience using insurance payer portals preferred.
• Experience with electronic medical records and practice-management systems preferred.
• Strong attention to detail and accuracy.
• Excellent organizational and time-management skills.
• Ability to prioritize multiple requests and meet strict deadlines.
• Strong written and verbal communication skills.
• Ability to communicate professionally with insurance representatives, patients, providers, and coworkers.
• Ability to work independently while functioning effectively as part of a team.
• Strong problem-solving and follow-up skills.

Ideal Candidate

Doesn’t let pending authorizations fall through the cracks. Understands that an incorrect or missing authorization can result in a significant claim denial. Persistent when dealing with insurance companies. Can interpret insurance requirements and determine what documentation is needed. Pays close attention to procedure codes, diagnosis codes, dates, providers, and authorization numbers. Communicates problems before they become scheduling or billing problems. Can manage a high volume of requests without sacrificing accuracy. Understands the importance of protecting both patient access to care and the practice’s revenue.

Key Performance Expectations

• Timely submission of authorization requests.
• Accurate authorization documentation.
• Timely follow-up on pending requests.
• Reduction of authorization-related claim denials.
• Minimization of appointment and procedure delays caused by missing authorizations.
• Accurate communication of authorization information to the appropriate departments.
• Proper documentation of denials, appeals, and payer correspondence.
• Consistent adherence to payer and practice requirements.

Skills

Insurance Knowledge | Prior Authorization | OBGYN Knowledge | Medical Terminology | CPT/ICD-10 | Organization | Attention to Detail | Follow-Up | Communication | Problem Solving | Time Management

The Goal of This Position

The Prior Authorization Specialist plays a critical role in keeping the OBGYN practice running efficiently by ensuring that necessary insurance approvals are obtained before services are rendered, patients are not unnecessarily delayed, and the practice is protected from preventable insurance denials.

“We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.”