Prior Authorization Specialist – Healthcare Access

Mercy Medical Center; United States; On-site; USD 42,000 - 64,000; Full time

Job summary

Mercy Medical Center is seeking a detail-oriented preauthorization specialist to ensure medical necessity and proper utilization of health care resources. You will manage authorizations across tests, procedures, and medications, verifying insurance benefits and coordinating with providers.

The role emphasizes accurate documentation, adherence to ICD-10 coding standards, and timely communication with patients and clinicians to resolve denials and obtain approvals.

Qualifications

• High school diploma or equivalent required.
• Experience in medical billing or healthcare administration preferred.
• Knowledge of ICD-10 coding and preauthorization processes required.
• Excellent communication and multi-tasking abilities.

Responsibilities

• Perform pre-authorization duties for tests, procedures, and medications.
• Obtain authorizations and assess medical necessity.
• Review requests for alignment with criteria.
• Verify patient insurance benefits and eligibility.
• Prepare and submit documentation to insurers.
• Understand ICD-10 LMPR, NCD and pre-authorization guidelines.
• Maintain records of authorizations, approvals, denials, and follow-ups.
• Resolve denied authorizations and resubmit as needed.
• Monitor AI 278 EDI transactions for attached records and approvals.
• Communicate with providers and patients; initiate waivers when denied.
• Call patients with cost and denial reasons.
• Use call manager and computer for duties.
• Follow safety guidelines.

Skills

Interpersonal skills

Customer service

Written communication

Oral communication

Multitasking

Education

High School Diploma or equivalent

Associates degree or HIM certification preferred

RHIT or RHIA certification preferred

Tools

EDI transactions monitoring

Preauthorization systems

Job description

Mercy Medical Center is seeking a detail-oriented preauthorization specialist to ensure medical necessity and proper utilization of health care resources. You will manage authorizations across tests, procedures, and medications, verifying insurance benefits and coordinating with providers.

The role emphasizes accurate documentation, adherence to ICD-10 coding standards, and timely communication with patients and clinicians to resolve denials and obtain approvals.