Prior Authorization Specialist

Koya Medical, Inc.; United States; Remote; USD 55,000 - 60,000; Full time

Job summary

Koya Medical, Inc. seeks a detail-oriented Prior Authorization Specialist to ensure timely payer approvals by managing authorizations, precertifications and referrals across multiple health plans.

You will educate payers on product features to support coverage and reimbursement while collaborating across departments to optimize patient access. Reporting to the Manager of Reimbursement Operations, this full-time, remote role requires 3+ years in prior authorization/reimbursement, strong insurance

Qualifications

• High school diploma required; Associate’s or Bachelor’s degree preferred.
• Minimum 3 years of experience in prior authorization and reimbursement processes.
• Background in medical devices, healthcare reimbursement, or related field.
• Strong understanding of insurance processes and authorization workflows.

Responsibilities

• Submit medical records and documentation to payers for coverage approval.
• Review clinical documentation to determine medical necessity.
• Process authorizations, precertifications, predeterminations, and referrals.
• Educate payers on product features and benefits to support coverage.
• Communicate payer findings clearly to internal stakeholders.

Skills

Insurance processes

Communication skills

Attention to detail

Independent and collaborative work

Payer portals navigation

Education

High school diploma

Associate's or Bachelor's degree preferred

Tools

Salesforce

Job description

Koya is always looking for curious and passionate individuals who want to join a fast-paced team for a career in transforming venous and lymphatic care through innovative people-centric technologies that improve lives and empower self-care. Koya values integrity, humility, hard-work, camaraderie, and fun. We offer a base + bonus compensation package, and a competitive benefits program.

Job Summary

The Prior Authorization Specialist ensures timely payer approvals by managing authorizations, precertifications, predeterminations, and referrals to maximize reimbursement for patients and the organization. This role involves educating payers on the Dayspring and applying strong insurance expertise to navigate complex authorization requirements across various health plans.

This role reports to the Manager, Prior Authorization within the Reimbursement Operations Department. The role is full time, exempt and will work remotely.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following:

• Submit medical records and documentation to payers for coverage approval, including network exceptions and single case agreements
• Review clinical documentation to determine medical necessity
• Process authorizations, precertifications, predeterminations, and referrals across multiple health insurance plans
• Educate payers on product features and benefits to support coverage and reimbursement
• Communicate payer process findings clearly to internal stakeholders
• Collaborate with internal departments to ensure accurate patient order processing
• Maintain compliance with HIPAA and all regulatory requirements
• Ensure accuracy while meeting productivity and quality standards
• Assist in developing internal workflows and best practices
• Perform other duties as assigned

Minimum Qualifications

Education, Experience and Training

High school diploma required; Associate’s or Bachelor’s degree preferred

Minimum 3 years of experience in prior authorization and reimbursement processes

Background in medical devices, healthcare reimbursement, or related field

Knowledge, Skills and Abilities

Strong understanding of insurance processes and authorization workflows

Excellent written and verbal communication skills

High attention to detail with strong organizational and multitasking skills

Ability to work independently and collaboratively in a fast-paced environment

Proficient in navigating payer portals and Salesforce

Demonstrated ability to multitask, prioritize, and meet deadlines under pressure

Core Competencies

• Initiative & critical thinking
• Flexibility & adaptability

Tools and Technology

Physical Functions and Work Environment

The physical functions described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.

While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers; handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate.

Note

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any Koya manager authorized to provide instruction or assign work. Duties, responsibilities, and activities may change at any time with or without notice.

All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.

Koya Medical, Inc. is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

#LI-REMOTE

The pay range for this role is:

55,000 - 60,000 USD per year (Remote (United States))