Prior Authorization Representative
Job Title: Prior Authorization Representative
Client: Medical Device Manufacturing Company
Duration: 24 Months with possibility of extension
Location: Virtual / Remote
Shift: 1st Shift
Experience: 2+ Years Relevant Experience
Description:
Job Summary
The Prior Authorization Representative is responsible for verifying insurance coverage, determining prior authorization requirements, submitting authorization requests, and following up with physician offices and payers to support patient access to therapies.
The role also handles authorization denials, retro authorizations, special cases, and customer service activities while maintaining accurate documentation and communication with internal and external stakeholders.
Key Responsibilities
- Verify patient insurance coverage, benefits, and prior authorization requirements.
- Initiate and submit prior authorization requests when required.
- Coordinate required paperwork, clinical notes, and forms for authorization submissions.
- Frequently follow up with payers and stakeholders to monitor authorization status.
- Assist with prior authorization appeals, retro authorizations, and special cases.
- Maintain knowledge of payer payment processes and prior authorization procedures.
- Apply familiarity with ICD-9/10 and CPT codes and maintain detailed knowledge of applicable therapy codes.
- Communicate professionally with: Physician offices, Payers and payer representatives, Sales representatives, Utilization reviewers, Internal and external stakeholders
- Provide high-quality customer service and resolve inquiries.
- Answer product-related questions and trace lost shipments.
- Interpret and clarify customer orders for the shipping department.
- Take orders by phone and support web-based ordering when required.
- Coordinate customer credits, returns, pricing adjustments, and related issues.
- Identify and document quality assurance complaints.
- Support inventory activities at customer facilities using EDI, forecasting, replenishment, and inventory systems when required.
- Assist with stock allocation and service-level issues.
Required Skills & Qualifications
- 2+ years of relevant experience required.
- Strong knowledge of systems, procedures, and administrative processes.
- Experience with prior authorization and insurance verification.
- Strong knowledge of payer authorization processes.
- Familiarity with ICD-9/10 and CPT codes.
- Advanced Microsoft Excel skills.
- Ability to learn and use multiple CRM systems.
- Excellent written and verbal communication skills.
- Strong organizational and multitasking abilities.
- Strong critical-thinking and problem-solving skills.
- High attention to detail.
- Ability to work effectively with both internal and external customers.
Additional Skills
- Knowledge of healthcare payer processes.
- Experience handling authorization denials and appeals.
- Experience with customer orders, shipping, returns, credits, or inventory support.
- Familiarity with EDI, forecasting, replenishment, and inventory systems.
- Ability to work independently under moderate supervision.
- Ability to identify routine process issues and recommend solutions.
