Prior Authorization Coordinator

Description

The Prior Authorization Coordinator serves as a liaison between medical providers, insurance companies (payors), and patients. Their primary function is to secure approval from insurance carriers for medical procedures, medications, or treatments before they are administered, ensuring both clinical necessity and financial coverage.

Location: Knoxville, TN – GI for Kids

Job Type: Full-Time

Why You’ll Love This Role:

• No nights, no weekends, no on-call
• Monday–Friday, standard business hours
• Office closed on major holidays
• Full benefits package (Medical, Dental, Vision, PTO, 401k with match, and more!)

Core Responsibilities:

• Insurance Verification: Confirming patient eligibility and benefit coverage details, including co-pays and deductibles, prior to services.
• Request Submission: Preparing and submitting detailed authorization requests through payer portals, fax, or phone, ensuring all required clinical documentation and diagnosis/procedure codes (ICD-10, CPT) are included.
• Status Tracking: Monitoring pending requests and following up with insurance companies to ensure timely approvals and prevent delays in patient care.
• Denial Management & Appeals: Reviewing reasons for denied authorizations and initiating the appeals process by gathering additional medical records or coordinating peer-to-peer reviews between physicians and insurance medical directors.
• Provider & Patient Communication: Updating clinical staff on authorization status and educating patients on their insurance requirements and potential financial responsibilities.
• Record Maintenance: Entering and updating authorization numbers and expiration dates into Electronic Health Record (EHR) or Practice Management systems for accurate billing.

Requirements

Key Requirements & Qualifications

• Education: Typically requires a High School Diploma or GED; however, many employers prefer an associate or bachelor’s degree in healthcare administration or a related field.
• Experience: Most roles require 1–3 years of experience in medical billing, insurance verification, or a clinical office setting.
• Clinical Knowledge: Proficiency in medical terminology, anatomy, and standard coding (ICD-10, CPT, HCPCS).
• Technical Skills: Expertise in using insurance portals (e.g., Availity, CoverMyMeds) and EHR systems.

Essential Skills

• Detail-Oriented: Precision in documenting clinical data to minimize the risk of claim denials.
• Time Management: Ability to prioritize urgent authorization requests, especially for time-sensitive treatments like oncology or surgery.
• Problem-Solving: Identifying missing information in medical charts and navigating complex, changing insurance policies.
• Communication: Professional verbal and written skills for negotiating with insurance adjusters and explaining complex processes to stressed patients.