Prior Authorization Specialist: Payer & Compliance Expert

Navajo Health Foundation; Ganado (AZ); On-site; USD 42,000 - 60,000; Full time

Job summary

Navajo Health Foundation in Ganado, AZ seeks a dedicated Prior Authorization Specialist to verify insurance coverage, obtain authorizations, and ensure medical necessity for hospital services. You will coordinate with providers, coders, HIM, and payers to secure documentation and accurate coding for timely reimbursement.

Responsibilities include reviewing payer policies, submitting required records, and following up on authorization progress while maintaining HIPAA compliance and patient

Qualifications

• High School Diploma or GED.
• 1–2 years in clerical support, patient registration, or insurance verification in a hospital/medical office.
• Maintain confidentiality and comply with HIPAA regulations.
• Basic understanding of commercial insurance, Medicare, Medicare Advantage, Medicaid/AHCCCS, and payer authorization requirements.

Responsibilities

• Understand payer policies, authorization requirements, and timeframes, ensuring compliance with regulations and hospital policies.
• Verify patient demographics and confirm insurance coverage.
• Obtain prior authorizations for admissions, services, procedures.
• Coordinate with coders for CPT/diagnosis codes for authorization submission.
• Document approvals, reference numbers, and status in required systems.
• Review daily schedules to identify patients needing verification or prior authorization.
• Ensure clinical documentation is complete and submitted to payers.
• Collaborate with Health Information Management to obtain requested records for payers.
• Follow up with insurers to confirm receipt and monitor progress.
• Assist with addressing denials and appeals, including Peer-to-Peer requests.
• Notify management of changes or trends in authorization requirements.
• Refer uninsured patients to Patient Benefits Coordinator or AHCCCS applications.

Skills

Bilingual English and Navajo

Verbal communication

Written communication

HIPAA compliance

Customer service

Office software

Education

High School Diploma / GED

Tools

MEDITECH Expanse

Job description

Navajo Health Foundation in Ganado, AZ seeks a dedicated Prior Authorization Specialist to verify insurance coverage, obtain authorizations, and ensure medical necessity for hospital services. You will coordinate with providers, coders, HIM, and payers to secure documentation and accurate coding for timely reimbursement.

Responsibilities include reviewing payer policies, submitting required records, and following up on authorization progress while maintaining HIPAA compliance and patient