Prior Authorization Specialist

MML US Inc; San Diego (CA); Sur place; USD 75 000 - 85 000; Plein temps

Résumé du poste

Mainstay Medical is seeking a Prior Authorization Specialist to lead the PA process onsite in San Diego, coordinating with case management and reimbursement teams to secure timely access for patients. Strong knowledge of payer guidelines and medical necessity is essential.

This role emphasizes accuracy, persistence, and attention to detail, with a focus on reducing delays and denials while supporting physicians, patients, and field teams.

Qualifications

• Bachelor's degree or advanced degree with relevant experience; 2+ years in medical office, hospital, or payer with prior authorization.
• Knowledge of health insurance industry practices.
• Experience with Medicare, Medicaid, Tricare, Workers' Compensation, and Commercial Insurance.
• Excellent written and oral communication.
• Highly organized with attention to detail.
• Proficient in Microsoft Office and PowerPoint.
• Experience with Salesforce, Availity, eFax, and basic database tools.
• Problem-solver with ability to resolve challenges.
• Patient-centric, empathetic approach.

Responsabilités

• Own and manage the prior authorization process from submission to approval or denial.
• Submit accurate PA requests via payer portals.
• Collaborate with case management to align with payer policies.
• Maintain documentation and status updates in designated systems.
• Escalate complex or high-risk cases when needed.
• Identify process improvements and standardize resources.
• Ensure regulatory, privacy, and patient confidentiality compliance.

Connaissances

Communication

Attention to detail

Organizational skills

Problem solving

Empathy

Formation

Bachelor's degree

Outils

Microsoft Office

Salesforce

Availity

eFax

Description du poste

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Prior Authorization Specialist

Salary Range: $75,000.00 To $85,000.00 Annually

This position is onsite in San Diego.

Mainstay Medical

Mainstay Medical is a medical device company focused on marketing an innovative implantable neurostimulation system, ReActiv8®, for people with disabling chronic mechanical Low Back Pain. The company is headquartered in Dublin, Ireland, with subsidiaries operating in the United States, Australia, the United Kingdom, and Germany.

The Role:

The Prior Authorization Specialist plays a critical role in helping patients gain timely access to Mainstay Medical therapy by navigating the insurance authorization process with accuracy, urgency, and persistence. Working closely with Case Managers, and internal reimbursement and market access partners, the Prior Authorization Specialist helps ensure that each patient’s case is complete, well-supported, and positioned for efficient payer review.

It is a specialized patient-access position that requires strong reimbursement knowledge, disciplined follow-through, attention to detail, and the ability to resolve complex barriers. This is not a transactional paperwork role. The Prior Authorization Specialist serves as an internal subject-matter resource, helping move patients through the authorization process while reducing avoidable delays, preventable denials, and administrative burden on physician offices and field sales teams.

Position Responsibilities:

Prior Authorization Ownership

• Manage the prior authorization process as requested by the health care provider for assigned patients from initial submission through approval, denial resolution, or escalation.
• Maintain consistent accountability until the authorization process has been resolved.
• Contribute to the development of standardized resources, templates, and best practices.
• Documentation Review and Submission
• Communicate with case management to ensure that submissions align with payer policies, medical necessity criteria, and documentation standards.
• Submit prior authorization requests accurately and promptly through designated payer portals, systems, or communication channels.
• Monitor submissions closely and respond quickly to requests for additional information.

Payer and Reimbursement Fluency

• Review denial notices carefully in partnership with case management to determine the underlying issue and appropriate next step.
• Maintain working knowledge of payer requirements, authorization pathways, coverage criteria, and documentation expectations.
• Recognize differences across commercial payers, government programs, and regional reimbursement environments.
• Share payer and operational insights to strengthen strategy and foster a culture of accountability, responsiveness, and continuous improvement.
• Ensure all documentation and communication meet regulatory, privacy, and company requirements while protecting patient confidentiality.
• Use approved systems and workflows consistently to support audit readiness and disciplined process adherence.
• Escalate complex or high-risk cases appropriately and involve the right resources at the right time.
• Maintain accurate, timely documentation of payer interactions, submissions, authorization status, and follow-up activities.
• Partner and communicate closely with Case Managers to provide clear visibility into authorization status, barriers, and next-step priorities.
• Maintain accurate status information within designated systems.
• Collaborate cross-functionally to resolve cases and support patient access.
• Escalate complex or high-risk cases appropriately while identifying trends and recommending process improvements.

Qualifications:

• Bachelors degree and a minimum of 2 years related experience, or an advanced degree without experience, or equivalent work experience. Experience in a medical office, hospital setting, or payer with coding and prior authorization experience or utilization review.
• Knowledge of health insurance industry practices and functions.
• Experience with Medicare, Medicaid, Tricare, Workers Compensation, and Commercial Insurance.
• Superior oral and written communication skills.
• Demonstrates excellent organization skills with attention to detail.
• Proficient in Microsoft Office, including Microsoft Word, Outlook, Excel, and PowerPoint.
• Experience working with platforms such as Salesforce, Availity, eFax systems, and other basic database management programs.
• Problem solver and capable to find solutions to challenges or process impediments.
• Maintains a caring, empathetic, and patient-centric approach in all interactions.

The salary range for this position is $75,000 to $85,000/year; however, base pay offered will take into account a range of factors, including job-related knowledge, skills, and experience. The total compensation package includes a range of medical, dental, vision, financial, and other benefits, as well as equity.

Mainstay Medical is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to gender, race, color, religious creed, national origin, age, sexual orientation, gender identity, physical or mental disability, and/or protected veteran status. Mainstay Medical participates in E-Verify.