Prior Authorization Specialist

Las Vegas Pain Institute and Medical Center; Las Vegas (NV); On-site; USD 42,000 - 65,000; Full time

Job summary

Las Vegas Pain Institute and Medical Center in Las Vegas, NV is seeking a dedicated Prior Authorization Specialist. You will secure insurance approvals before procedures, coordinating between physicians, patients, and insurers to ensure medical necessity and minimize claim denials.

Responsibilities include compiling records, submitting requests, tracking status, handling denials with appeals, and communicating timelines and costs to patients and providers.

Qualifications

• Familiar with medical terminology, coding systems (ICD-10, CPT, HCPCS).
• Knowledge of payer policies, Medicare/Medicaid, HIPAA compliance.
• Experience with EHR systems such as Epic or Cerner and insurance portals.

Responsibilities

• Review patient records to gather information for payer requests.
• Submit authorization requests to insurance carriers.
• Track pending requests and follow up to avoid delays.
• Investigate denials and file appeals when needed.

Skills

Medical Terminology

Insurance Knowledge

Epic or Cerner experience

HIPAA Compliance

Communication Skills

Tools

Epic/EHR systems

Insurance Portals

Job description

Job Description

Job Description

** Job description:**

Prior Authorization/ B&E job description: A Prior Authorization Specialist: A prior authorization specialist is a healthcare administrative professional who secures approval from insurance companies before a patient undergoes specific procedures and/or treatments. They act as the vital link between doctors, patients, and insurance providers to ensure medical necessity and prevent claim denials. Their day-to-day responsibilities focus on smooth patient care and financial efficiency.

• Documentation & Submission: They review patient medical records and clinical notes to gather the exact information required by the payer. They then submit comprehensive authorization requests to insurance carriers
• Follow-up & Tracking: They monitor pending requests, navigate insurance portals, and follow up relentlessly to prevent delays in patient treatment
• Denial & Appeal Management: If an insurer rejects a request, the specialist investigates the issue, resubmits the forms, and files appeals to ensure the patient still gets the care they need.
• Patient & Provider Communication: They communicate directly with doctors' offices and explain the complex authorization process including potential timelines and financial implications to patients.

Prior authorization requires a mix of medical knowledge, administrative precision, and a strong interpersonal ability to get treatments approved by insurers

• The essential skills needed to succeed include:

Hard Skills & Technical Knowledge:

• Medical Terminology & Coding: You must understand medical terms, procedures, and diagnoses, often relying on ICD-10, CPT, and HCPCS codes.
• Insurance & Regulatory Knowledge: Deep familiarity with varying payer policies, Medicare/Medicaid guidelines, and HIPAA compliance.
• EHR/EMR Proficiency: Experience navigating Electronic Health Record systems (like Epic or Cerner ) and specific insurance portals

Administrative & Analytical Skills:

• Detail-Oriented: The ability to review patient files, pull precise clinical documentation, and ensure applications meet the strict "medical necessity" criteria
• Time Management: Because the approval process has tight deadlines and high volumes, you need the organizational skills to prioritize time-sensitive tasks and juggle multiple cases simultaneously.
• Problem-Solving: The ability to audit records, investigate denials, and submit successful appeals.

Soft Skills:

• Communication: Strong verbal and written communication are required to clearly explain "medical necessity" to insurance adjusters and convey approval/denial statuses to patients and doctors.
• Customer Service: A compassionate, empathetic approach is necessary when dealing with patients who may be anxious about treatment delays or unexpected out-of-pocket cost.

** Work Location: In person**