Pre-Authorization Specialist (Clinic)

Premier Medical Resources; Houston (TX); Hybrid; USD 42,000 - 62,000; Full time

Benefits offered by this job

Medical plans (3)

Vision plans (2)

Employee Assistance Program

Disability Insurance

401(k) with 2-year vesting

PTO + Holidays

Job summary

Premier Medical Resources, a healthcare management company in Northwest Houston, Texas, seeks a full-time Pre-Authorization Specialist. The role focuses on obtaining pre-certifications, pre-authorizations, and referrals with guidance from the Revenue Cycle Manager.

The position offers a hybrid work model after 30-90 days of in-person training, with responsibilities spanning CPT/ICD-10 coding, payer verification, and coordination across departments. Background check and drug screening apply.

Qualifications

• Knowledge of insurance verification and patient responsibility.
• Familiarity with ICD-10 and CPT codes and procedures.
• Ability to review medical documentation and understand medical necessity.

Responsibilities

• Prioritize authorization requests by urgency.
• Generate and oversee authorization/referral processes.
• Handle day-to-day pre-authorization issues and follow up.
• Notify departments for approvals/denials and coordinate appeals.

Skills

In/out-of-network insurances

ICD-10 CPT codes

Review medical documentation

Medical necessity requirements

Task-oriented & organized

Detail-oriented

Independent and team work

Flexible/adaptable

Downtime efficiency

Education

High school diploma or GED

2 years medical office/facility experience

Job description

Revenue Cycle Management is looking for a full-time Pre-Authorization Specialist to join our team! **Hybrid opportunity after 30-90 day in-person training**

SUMMARY:

The Pre-Authorization Specialist is primarily responsible for oversight in obtaining the required pre-certifications, pre-authorizations, and referrals for all services accurately and timely. Under the direction of the Revenue Cycle Manager, the employee will ensure that the processes within the department are functioning appropriately.

ESSENTIAL FUNCTIONS:

• Prioritize incoming authorization requests according to urgency.
• Generate, verify, and oversee the complete procedure authorization/referral process.
• Manage and resolve day-to-day issues pertaining to pre-authorization, as needed.
• Monitor provider network status and notify appropriate individuals of non-network status providers.
• Obtain authorization by fax, payer website or by phone and follow up regularly on pending cases.
• Notify appropriate departments for approvals and denials.
• Initiate and assist with appeals for denied authorizations.
• Notify and coordinate P2P (Peer to Peer) requests with the appropriate department.
• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order
• Contact patients as needed to discuss authorization status.
• Maintain, monitor, and update payer medical policy guidelines to manage authorization requirements.
• Request, review, and submit necessary patient documentation as needed.
• Assist with patient scheduling and inquiries, as necessary.
• Apply ICD 10, CPT, modifiers and/or other codes according to coding guidelines.
• Communicate with provider and/or all appropriate parties regarding missing information such as CPT, diagnoses codes, documents, clinical reports, etc. to ensure proper authorization processing.
• Communicate with other departments regarding changes and/or updates with patient accounts and status.
• Manage the status of accounts and identify inconsistencies.
• Respond to billing inquiries.
• Communicate company goals, expectations, updates, and/or deadlines timely.
• Make recommendations on workflow improvement as needed.
• Report statistics as required.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge with in and out of network insurances, insurance verification, patient responsibility, and process for prior authorization.
• Familiarity with ICD-10 and CPT codes and procedures.
• Ability to review and understand patient medical documentation.
• Ability to independently identify and understand medical necessity requirements.
• Task-oriented and organizational skills; ability to complete tasks timely
• Detail-oriented focus; being careful about detail and thorough in completing work tasks.
• Ability to work independently and as a team.
• Ability to adapt with flexibility.
• Uses downtime efficiently; is aware of team members workload.

EDUCATION AND EXPERIENCE:

• High school diploma or GED
• Two (2) years of medical office or facility setting experience

BENEFITS:

• 3 Medical Plans
• 2 Vision Plans
• Employee Assistant Program
• Short- and Long-Term Disability Insurance
• 401(k) with a 2-year vesting
• PTO + Holidays

Premier Medical Resources is a healthcare management company headquartered in Northwest Houston, Texas. At Premier Medical Resources, our goal is to leverage and combine the expertise and skillset of our employees to drive quality in all we do. Our goal is to create career pathways for our employees just starting their professional career, and to those who seek to bring their expertise and leadership as we strive to combine best practices and industry excellence. Come join our team at Premier Medical Resources where passion and career meet.

Compensation to be determined by the education, experience, knowledge, skills, and abilities of the applicant, internal equity, and alignment with market data. Employment for this position is contingent upon the successful completion of a background check and drug screening.