Prior Authorization Specialist

·         Processes prior authorizations accurately and efficiently, including reviewing step therapy, minimum authorization requirements, and payer-preferred medications.

·         Manages appeals and denials, escalating cases when necessary, and follows appropriate payer protocols.

·         Analyzes insurance policies for each case and communicates with internal teams or providers to obtain needed documentation when the case does not align with policy.

·         Verifies insurance benefits and determines in-network (INN) or out-of-network (OON) status across various payers and states under Intake standards.

·         Evaluates medical and pharmacy benefits to determine patient eligibility for treatment.

·         Maintains clear, professional communication with providers, patients, internal teams, and stakeholders.

·         Accurately documents all case-related conversations and updates within Salesforce within required timeframes.

·         Prioritizes personal tasks and authorizations to ensure timely completion and follow-up.

·         Collaborates with internal team members (e.g., PACs, clinical staff, sales) to gather or clarify case information.

·         Investigates and resolves complex cases using strong critical thinking and problem-solving skills.

·         Organizes and manages authorization workload efficiently to meet performance goals.

·         Follow and produce by Intake standards for accuracy and completion standards.

·         Minimum 2-3 years of experience as a Medical Assistant (MA), with direct prior authorization and biologic therapy experience.

·         Proven ability to interpret clinical documentation and understand commercial and Medicare Advantage policies, including Local Coverage Determinations (LCDs).

·         Strong experience working with systems like Salesforce, WeInfuse, and AMD.

·         Background in a specialty field such as Rheumatology, Gastroenterology, Dermatology, Neurology, or Immunology preferred.

·         Excellent communication and customer service skills with both clinical teams and patients.

·         Highly organized and capable of managing multiple priorities in a fast-paced environment.

·         Strong documentation habits and time management skills.

·         Education/Licensure/Technical Requirements

·         High School diploma or equivalent required.

·         Certification or formal training as a Medical Assistant required

·         Biologic Authorization experience required

·         Must meet U.S. employment eligibility requirements.

·         Proficiency with EMRs, CRMs (Salesforce), and prior authorization systems.

·         Works comfortably in software like a PMS or EMR to track information, schedule and make notes.

·         Ability to meet U.S. employment and eligibility requirements