Medication Prior Authorization Specialist

Description

Tanner Clinic has an immediate opening for a Medication Prior Authorization Specialist.

Department: Scheduling

Reports To: Scheduling Manager

FLSA Status: Non-Exempt (Hourly)

Supervisory Responsibilities: None

Job Summary

The Prior Authorization Specialist is responsible for obtaining insurance authorization and approval for prescribed medications by working collaboratively with providers, clinical staff, pharmacies, insurance companies, and patients. This role ensures timely processing of prior authorizations, appeals, and related documentation to minimize delays in patient care while maintaining compliance with payer requirements and organizational standards.

Essential Job Responsibilities

Authorization Management

• Review medication prior authorization requests submitted by providers and clinical staff.
• Submit prior authorization requests through payer portals, electronic systems, fax, or phone as required.
• Gather and review clinical documentation necessary to support authorization requests.
• Monitor authorization status and follow up with insurance companies to ensure timely resolution.
• Process medication denials and coordinate appeal submissions when appropriate.

Communication & Customer Service

• Communicate with providers regarding payer requirements, formulary alternatives, and authorization outcomes.
• Collaborate with pharmacies, patients, providers, and insurance representatives to resolve authorization issues.
• Assist patients with understanding authorization requirements and provide status updates as needed.

Documentation and Compliance

• Maintain accurate documentation of all authorization activities within the electronic medical record (EMR) and other tracking systems.

Performance & Continuous Improvement

• Identify opportunities to improve authorization turnaround times and workflow efficiency.
• Meet established productivity, quality, and turnaround time expectations.

Requirements

Performance Requirements

Knowledge

• Knowledge of payer guidelines and pharmacy benefit management (PBM) processes.
• Knowledge of medical terminology, insurance plans, and prior authorization processes.
• Experience working with electronic medical records (EMR) systems.

Skills

• Strong attention to detail and organizational skills.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office and other computer applications.

Abilities

• Ability to manage multiple priorities in a fast-paced environment.

Education & Experience Requirements

Education

• High school diploma or equivalent.
• Credentialed as a Medical Assistant or higher.

Experience

• 3-5 years of experience working in a hospital, physician's office, or pharmacy setting, with knowledge of medical procedures and/or medication prior authorization processes, required.
• 1-2 years of medical procedure and/or prior medication authorization experience preferred.

Physical & Environmental Requirements

Environment

• Professional, well-lighted office setting.

Physical Demands

• Primarily sedentary work involving sitting approximately 90% of the time, with occasional standing or walking.

Attendance

• Regular and reliable attendance is an essential function of this role.