Prior Authorization and Appeals Specialist

AscellaHealth; Berwyn (PA); Hybrid; USD 40,000 - 65,000; Full time

Job summary

An established industry player is seeking a Prior Authorization and Appeals Specialist to enhance the efficiency of their operations. This dynamic role involves managing the complexities of prior authorizations and appeals, ensuring compliance with federal regulations while providing exceptional service to clients. The position starts with in-office training and transitions to a hybrid work model, offering flexibility based on business needs. Join a dedicated team that focuses on supporting smaller patient communities through personalized care and proactive services. If you thrive in a detail-oriented environment and have a passion for healthcare, this opportunity is perfect for you.

Qualifications

• 2+ years of experience in medical/pharmacy insurance verification.
• Knowledge of medical terminology and insurance benefits coding.

Responsibilities

• Manage prior authorizations and appeals with health insurance companies.
• Document activities and respond to denials effectively.
• Collaborate with departments for resolution and maintain documentation standards.

Skills

Medical/Pharmacy Insurance Verification

Prior Authorizations Knowledge

Claim Appeals Knowledge

Attention to Detail

Critical Thinking Skills

Communication Skills

Interpersonal Skills

Microsoft Office Proficiency

Education

High School Diploma or Equivalent

Job description

Prior Authorization and Appeals Specialist

Optime Care seeks a Prior Authorization and Appeals Specialist for our Berwyn, PA location. This role manages the process of receiving, researching, and resolving prior authorizations and appeals issues with health insurance companies, following federal regulatory requirements, policies, and procedures.

Initially, the position requires in-office presence five days a week for training, transitioning to a hybrid model with 3-4 days in-office based on business needs.

Responsibilities

• Ensure cases follow guidelines and timeliness criteria, communicating with providers and insurance companies
• Document all activities related to prior authorizations and appeals
• Respond to denials, submit appeals, and gather clinical support
• Draft technical denial arguments for reconsideration
• Overcome objections to secure claim payments through effective appeals
• Identify payor issues and escalate as needed
• Maintain documentation standards for a comprehensive record
• Finalize and send letters of determination
• Manage correspondence within required timeframes
• Collaborate with other departments for resolution
• Prepare case files for appeals and audits
• Work with clients to analyze payer response trends
• Support departmental initiatives and adapt to work schedule needs

Minimum Qualifications

• High school diploma or equivalent
• At least 2 years of experience in medical/pharmacy insurance verification and benefit investigation
• Knowledge of prior authorizations and claim appeals
• Understanding of medical terminology
• Current Missouri BOP Pharmacy Technician license
• Familiarity with insurance benefits language and coding (EOBs, CPT, HCPCS, ICD, NDC)
• Ability to work independently and meet productivity standards
• Strong attention to detail and critical thinking skills
• Proficiency in Microsoft Office
• Excellent communication and interpersonal skills
• Willingness to support flexible schedules across time zones

About Us

Optime Care is a Specialty Pharmacy dedicated to supporting smaller patient communities through insurance coverage, care coordination, and therapy compliance. Our mission is to reduce the daily impact of living with complex disorders, providing personalized, proactive services.

We are an equal opportunity employer committed to diversity and inclusion.