Insurance Authorization Coordinator I

Prior Authorization Coordinator I plays a critical role in the patient care continuum by executing accurate, timely medical insurance verification and securing essential prior authorizations. Operating at the intersection of clinical care and revenue cycle management, this position ensures patients receive prompt access to life-altering specialty medications and home infusion therapies while safeguarding the organization against financial risk and enabling seamless reimbursement.

Responsibilities

Screen and prioritize orders requiring benefits investigation and medical prior authorization; Review the completeness of payers documented in each patient's insurance profile; Identify patient's primary, secondary, tertiary, or supplemental plans; Generate and utilize reports to track ongoing monthly patient eligibility verifications; Identify and inform providers and patients regarding network providers and network participation status; Submit prior authorization requests to medical plans and coordinate case reviews with clinical staff; Generate expiring medical authorization reports and initiate reauthorization requests; Maintain a full caseload while meeting or exceeding operational metrics and turnaround timeframes; Run pharmacy test claims and contact payers to verify member coverage; Document all payer communications, including representative name, phone number, and call reference number; Document detailed medical authorization status updates on patient accounts; Answer inbound medical authorization calls and provide customer service to patients, doctors' offices, and internal departments; Obtain and communicate clinical information or medical records with providers to appeal denied or pending authorizations; Identify changes in patient medical plan coverage and coordinate new payer information with Billers; Create and utilize reminders and follow-up reports to ensure completion of pending activities; Escalate unresolved benefits investigations and prior authorization issues to management; Ensure compliance with payer rules, regulations, and company policies; Perform alternative tasks and duties as assigned by leadership

Requirements

At least 2 years of experience in specialty pharmacy, home infusion, medical billing, and medical/pharmacy authorization processes; Experienced as a medical coder/biller with a working knowledge of managed care, commercial insurance, Medicare, and Medicaid reimbursement; Knowledge of ICD 10, CPT, HCPC and J billing codes and medical terminology, with CMS HCFA 1500 form & Electronic Billing; Knowledge of Benefit Investigation and Patient Responsibility Agreements; Knowledge of automated billing systems; Advanced knowledge of Word, Excel, and Outlook functions; Ability to read, write, speak, and understand the English language; Strong interpersonal skills with a service-oriented mindset; Ability to support colleagues in a fast-changing environment and cooperate across teams for all pharmacy needs; Ability to apply common sense understanding, logical thinking, and data analysis to resolve abstract and concrete problems; Excellent time management, multi-tasking, and prioritization skills with the ability to work independently under minimal guidance; High accuracy in typing and data entry; Ability to work the hours required to ensure all projects and daily duties are completed in a timely manner

Benefits

Full benefits package including medical, dental, vision, life; Great pay and general compensation structures; Employee assistance program for mental health, legal questions, financial counseling; Comprehensive PTO and sick leave options; 401k program; Plenty of opportunities for growth and advancement; Company sponsored outings and team-building events; Casual Fridays