Prior Authorization Specialist

CardioOne; Philadelphia (Philadelphia County); Remote; USD 29,000 - 37,000; Full time

Job summary

CardioOne is seeking an experienced Prior-Authorization Specialist to obtain and verify authorizations for procedures, tests, and services. You will ensure timely approvals while complying with insurer policies and healthcare regulations, collaborating with providers, patients, and insurance representatives.

You will report to the Associate Director of Revenue Cycle Management and contribute to accurate documentation, eligibility checks, and escalation to peer-to-peer review as needed.

Qualifications

• 3–5 years in prior authorizations or related healthcare role
• Familiar with medical office procedures and billing practices
• Cardiology experience preferred
• Athena experience required
• Proficient in clinical documentation review for insurance authorizations
• Compliance with OSHA, HIPAA, and fraud and abuse laws

Responsibilities

• Obtain and verify timely prior authorizations before services
• Verify insurance eligibility and benefits for identified services
• Check pre-certification, authorization, and referral requirements
• Provide payer with medical records and letters of necessity when needed
• Escalate to peer-to-peer review as required
• Communicate with patients and providers to facilitate authorization
• Prioritize urgent cases and document all applications
• Follow policies if authorization not obtained before service date
• Answer questions about authorization requirements
• Handle escalated authorization requests
• Mentor teammates as needed
• Perform other duties as assigned

Skills

Medical office procedures

Billing practices

Cardiology experience

Athena experience

Clinical documentation review

Education

Associate degree (healthcare administration or business)

Job description

About the Company

The next generation of independent cardiology is being built here. CardioOne is a physician-led, technology-driven cardiology platform built to empower independent practices to compete, and win, in a rapidly evolving healthcare landscape. Our mission is to provide cardiologists with the tools, infrastructure, and expertise they need to thrive while maintaining full clinical independence. We believe the best care is delivered by physicians who are empowered - not constrained - by the systems around them. We combine a deep bench of healthcare operators with purpose-built technology and AI-enabled solutions across operations, revenue cycle, imaging, and practice development. From real estate and advanced imaging to clinical workflows and data infrastructure, CardioOne delivers a fully integrated platform designed to drive growth, efficiency, and superior patient outcomes. Backed by WindRose Health Investors and leading healthcare executives, CardioOne is building one of the most sophisticated and scalable cardiology MSOs in the country - designed to reimagine what is possible for independent cardiology.

About the Job

We're seeking an experienced, detail-oriented Prior-Authorization Specialist to join our team at CardioOne. You will be responsible for obtaining and verifying prior authorizations within the appropriate timeline for procedures, diagnostic tests, and other services. This role ensures that all requests comply with insurance company policies, guidelines, and healthcare regulations. The specialist will collaborate with healthcare providers, patients, and insurance representatives to obtain the necessary approvals. You will report directly to the Associate Director of Revenue Cycle Management.

What you'll do:

• Ensure timely and accurate insurance authorizations are in place prior to services being rendered.
• Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt.
• Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services.
• Coordinates and supplies information to the review organization (payer) including medical record information and/or letter of medical necessity for determination of benefits.
• Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review.
• Communicates with patients, clinical partners, financial counselors, and others as necessary to facilitate the authorization process.
• Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner.
• Completes accurate documentation in all applications.
• Follows departmental policies and procedures, when necessary, authorization is not obtained before the service date.
• Answers provider, staff, and patient questions surrounding insurance authorization requirements.
• Handles escalated authorization requests as needed.
• Provides team mentorship as needed.
• Other duties as assigned.

What you'll need:

• Associate's degree in healthcare administration or business administration preferred
• A minimum of 3-5 years' experience in the same role, or related field in a healthcare setting is required.
• Familiarity with medical office procedures and billing practices
• Cardiology experience preferred.
• Athena experience required.
• Proficient in clinical documentation review for alignment with insurance authorization requirements
• Responsible for compliance with all regulatory requirements and/or guidelines. These requirements/guidelines include, but are not limited to: OSHA, HIPAA, Federal Fraud and Abuse laws.

Work Location:

Remote: Colorado (Denver preferred), Delaware, Florida, New Hampshire, New Jersey, Pennsylvania, Texas.

Additional Information

Full time position with an hourly range of $21.00-$27.00 dependent on years of relevant experience. This role will have medical, dental, and vision benefits along with a matching 401K.