Job Title: Prior Authorization Specialist
Department: Revenue Cycle / Billing
Reports To: Sr. Director of Billing and Reimbursement
Location: Onsite Preferred – Work From Home
Position Summary
The Prior Authorization Specialist is responsible for the timely and accurate submission of prior authorizations for Category I molecular pathology testing. The role requires reviewing clinical documentation, applying payer-specific medical necessity criteria, and ensuring alignment between CPT and ICD-10 coding. This position supports revenue cycle performance by minimizing authorization-related denials and delays.
Core Responsibilities
Submit and manage high-volume prior authorizations (~75-100 per day)
Review and interpret medical records, clinical documentation, and lab requisitions
Responsible for reviewing and submitting authorization level appeals
Data entry, correct insurance assignment to patient accounts, insurance eligibility verification
Review/update demographics and patient information for accuracy
Ensure appropriate linkage between CPT codes and ICD-10 diagnoses
Apply payer policies across Commercial, Medicare Advantage, and Medicaid payers
Utilize payer portals, automated tools, and internal systems to process authorizations
Monitor and track authorization statuses and complete required follow-up actions
Collaborate with internal billing teams to resolve authorization discrepancies
Maintain full compliance with HIPAA regulations and payer guidelines
Minimum Qualifications
2–4 years of relevant experience in:
Prior authorization processing
Laboratory billing
Healthcare revenue cycle
High school diploma required; some college preferred
Working knowledge of:
CPT coding (molecular preferred)
ICD-10 coding and medical necessity guidelines
Ability to interpret clinical documentation and testing requests
Strong knowledge and experience with Microsoft Excel as well as Word and Outlook, general office equipment, and ten-key by touch
Ability to easily adapt to increased business demands
Skills & Competencies
Strong analytical and critical thinking skills
High level of attention to detail and accuracy
Ability to interpret and apply payer policies
Effective internal communication skills
Ability to work in a high-volume, production-driven environment
Strong organizational and multi-tasking capabilities
Self-starter, ability to work independently.
Excellent communication and customer service skills; cooperative, work collaboratively and treat others in respectful, professional and supportive manner.
Desire to learn and apply learned concepts to various situations.
Tools & Systems
Salesforce
Glidian
XIFIN
Payer portals and automated authorization platforms
Microsoft Excel
Performance Expectations
Meet or exceed daily productivity Clients (authorization volume)
Maintain high accuracy and data integrity
Ensure timely submission and follow-up
Adhere to payer requirements and compliance standards