PRIOR AUTHORIZATION SPECIALIST

Navajo Health Foundation; Ganado (AZ); On-site; USD 42,000 - 60,000; Full time

Job summary

Navajo Health Foundation in Ganado, AZ seeks a dedicated Prior Authorization Specialist to verify insurance coverage, obtain authorizations, and ensure medical necessity for hospital services. You will coordinate with providers, coders, HIM, and payers to secure documentation and accurate coding for timely reimbursement.

Responsibilities include reviewing payer policies, submitting required records, and following up on authorization progress while maintaining HIPAA compliance and patient

Qualifications

• High School Diploma or GED.
• 1–2 years in clerical support, patient registration, or insurance verification in a hospital/medical office.
• Maintain confidentiality and comply with HIPAA regulations.
• Basic understanding of commercial insurance, Medicare, Medicare Advantage, Medicaid/AHCCCS, and payer authorization requirements.

Responsibilities

• Understand payer policies, authorization requirements, and timeframes, ensuring compliance with regulations and hospital policies.
• Verify patient demographics and confirm insurance coverage.
• Obtain prior authorizations for admissions, services, procedures.
• Coordinate with coders for CPT/diagnosis codes for authorization submission.
• Document approvals, reference numbers, and status in required systems.
• Review daily schedules to identify patients needing verification or prior authorization.
• Ensure clinical documentation is complete and submitted to payers.
• Collaborate with Health Information Management to obtain requested records for payers.
• Follow up with insurers to confirm receipt and monitor progress.
• Assist with addressing denials and appeals, including Peer-to-Peer requests.
• Notify management of changes or trends in authorization requirements.
• Refer uninsured patients to Patient Benefits Coordinator or AHCCCS applications.

Skills

Bilingual English and Navajo

Verbal communication

Written communication

HIPAA compliance

Customer service

Office software

Education

High School Diploma / GED

Tools

MEDITECH Expanse

Job description

Job Details: Job Location: Ganado, AZ 86505, Position Type: Full Time, Position Summary:The Prior Authorization Specialist is responsible for verifying insurance coverage, securing prior authorizations, and ensuring medical necessity requirements are met for all services provided at Sage Memorial Hospital. This role supports timely patient care and accurate reimbursement by coordinating with providers, coders, Health Information Management, and insurance payers to obtain required clinical documentation and coding. The Specialist maintains compliance with payer guidelines, monitors authorization trends, and contributes to the organization’s mission and core values through accuracy, communication, and consistent workflow execution.This list of duties and responsibilities is illustrative only of the task performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Understand payer policies, authorization requirements, and required timeframes, ensuring compliance with all governmental regulations, including healthcare billing standards, HIPAA, TJC, EMTALA, and Sage Memorial Hospital policies and procedures.
• Verify patient demographics and confirm primary, secondary, and tertiary insurance coverage.
• Obtain prior authorizations for inpatient admissions, outpatient services, clinical procedures, and surgical procedures.
• Request CPT and diagnosis codes from coders when clarification or additional coding is required for authorization submission.
• Document authorization approvals, reference numbers, and status updates in all required systems.
• Review daily schedules to identify patients requiring insurance verification or prior authorization.
• Ensure all required clinical documentation is complete, accurate, and submitted to payers for review.
• Collaborate with Health Information Management to obtain any clinical documentation requested by insurance payers, including discharge summaries, lab results, imaging reports, and other required records, ensuring timely submission of required records.
• Follow up with insurance companies to confirm receipt of documentation and monitor authorization progress.
• Coordinate with providers to address authorization denials and assist with appeals, including Peer-to-Peer requests.
• Notify management of changes, trends, or issues related to authorization requirements or payer processes.
• Research and correct inaccurate insurance information in Meditech Expanse.
• Refer uninsured and underinsured patients to the Patient Benefits Coordinator or assist with AHCCCS applications when appropriate.
• Complete daily productivity worksheets and maintain accurate work logs.
• Assist Admissions & Registration staff as assigned by management.
• Attend discharge planning meetings when requested.
• Perform additional duties, special projects, or assignments as needed.

Qualifications: Minimum Qualifications:

• High School Diploma or General Equivalency Diploma (GED).
• One to two years of progressive work experience in clerical support, patient registration, or insurance verification in a hospital or medical office setting.
• Maintain confidentiality and comply with HIPAA regulations.
• Basic understanding of commercial insurance, Medicare, Medicare Advantage Plans, Medicaid/AHCCCS, and payer authorization requirements.
• Must successfully pass all Employee Health Program requirements and pass a background investigation.

Knowledge, Abilities, Skills, and Certifications:

• Ability to communicate well in both English and Navajo.
• Strong verbal and written communication skills, including the ability to communicate effectively with internal and external customers.
• Ability to maintain professional, respectful, and compassionate attitude.
• Ability to work efficiently, tactfully, and with consideration for patient needs.
• Proficient computer skills and ability to operate standard office equipment.
• Ability to perform job duties with minimal supervision.
• Ability to manage multiple tasks, prioritize workload, and maintain accuracy.
• Knowledge of basic medical terminology, insurance processes, and prior authorization workflows.
• Understanding of clinical documentation types such as discharge summaries, lab results, and imaging reports.
• Familiarity with MEDITECH Expanse or similar electronic health record systems.

Physical Demands:

While performing the duties of this job, the employee regularly is required to sit; use arms and hands to reach and grasp objects; talk and hear. The employee frequently is required to walk. The employee occasionally is required to stand; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment:

Work schedule is Monday through Friday, 8am to 5pm. Extended hours and irregular shifts required as needed. Work is generally performed in an office with moderate noise level.