Prior Authorization Tech

JOB DESCRIPTION
JOB TITLE: Prior Authorization Tech or RN
DEPARTMENT: HIM (Health Information Management)
JOB RELATIONSHIPS:
Reports:
Responsible To: HIM Manager
Responsible For: Does not supervise other employees
Interrelationships: Works cooperatively with all clinic and hospital departments, medical staff, patients and visitors.
JOB SUMMARY:
The Prior Authorization (PA) Tech works under the supervision of the HIM Manager. The PA Tech reviews requests for medical services, medications, or procedures, ensuring they meet clinical criteria, payer rules, and regulations before approval, acting as a crucial link between providers, patients, and insurers to facilitate necessary care while managing costs and documentation, often involving phone calls, record review, and data entry in health systems.
JOB QUALIFICATIONS:
Experience:
Previous experience in a healthcare setting is preferred.
Education:
Prior-Authorization Tech
High School Diploma or equivalent
Associate's Degree or certified in medical billing, coding, or healthcare administration, preferred.
Certifications preferred in the following areas: CPC, CCA, CMAA.
KEY COMPETENCIES:
Excellent written and verbal communication skills
Strong critical thinking and problem-solving.
Strong organizational, planning, time management and prioritizing skills
Proficiency in MS Office and patient management software and databases.
Understanding of medical terminology and coding. (beneficial)
(PA) Tech role requires administrative skills with attention to detail, data entry, and insurance verification and coordination.
(PA) RN role requires clinical assessment of medical necessity, reviewing benefits, and clinical judgement.
This list is not exhaustive and may be supplemented as necessary.
JOB RESPONSIBILITIES:
Receive, process, and log authorization requests for services, medications, or procedures.
Review patient records.
Gather necessary documentation and process requests. Contact providers, pharmacies or patients for missing clinical documentation or clarification.
Handles phone calls with insurance providers.
Data entry, accurately update patient and authorization data in medical management systems.
Coordinate with providers, administrators and sometimes patients via phone, fax or electronic portals.
Track pending requests and follow up to ensure timely approval.
Assist with HCAHPS, Quality projects, and other duties as assigned.
Verify patient eligibility and benefits.
Act as a liaison between providers, patients, and the clinical team.
Assist in assembling and submitting necessary paperwork.
This list is not exhaustive and may be supplemented as necessary.
WORKING CONDITIONS:
Occasionally exposed to the risk of blood borne diseases.
Contact with patients under a wide variety of circumstances.
Occasionally exposed to unpleasant elements (accidents, injuries and illness)
Subject to varying and unpredictable situations.
ESSENTIAL FUNCTIONS:
Light to Medium physical effort (lift/carry up to 50 lbs.)
Occasional standing/walking
Occasionally lifts supplies/equipment
Eye-hand coordination
This list is not exhaustive and may be supplemented as necessary.
PHYSICAL REQUIREMENTS:
Level 3 (Available upon request)

Employment type
Full-Time

Work arrangement
No