Prior Authorization Specialist
Location
United States
Posted
1 day ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Prior Authorization Specialist
Mendelia
Role Description Mendelia is hiring a Prior Authorization Specialist to support end-to-end prior authorization workflows for specialty medical services, procedures, imaging, therapy, and medications. In this role, you will work closely with Mendelia’s internal operations team, clinic staff, payer portals, and insurance companies to: - Gather documentation - Submit requests - Track outcomes - Resolve issues that could delay patient care This is a great fit for someone who is detail-oriented, highly organized, comfortable working across multiple systems, and excited to help build a better prior authorization experience for specialty practices. What You’ll Do: - Initiate, submit, and track prior authorization requests for medical services, procedures, imaging, physical therapy, specialty medications, and other clinic needs across payer portals, fax, phone, and other submission methods. - Review patient insurance information, benefits, clinical documentation, diagnosis codes, CPT/HCPCS codes, modifiers, payer requirements, and medical necessity criteria before submission. - Collect, verify, and organize required documentation, including chart notes, imaging reports, PT notes, operative plans, diagnosis codes, medical necessity forms, and payer-specific forms. - Identify missing or incomplete information and coordinate with clinic staff, providers, and internal Mendelia team members to obtain what is needed. - Submit authorization requests accurately and on time using payer portals such as Availity, Carelon, Turning Point, UHC, Cigna, Aetna, and other payer-specific systems. - Follow up on pending cases, respond to payer inquiries, check statuses, escalate delays, and ensure deadlines are met to prevent disruption to patient care. - Document all actions, communications, submission details, case numbers, payer responses, and outcomes in Mendelia’s internal systems. - Communicate authorization updates clearly and proactively to internal team members and clinic stakeholders. - Support denial follow-up, reconsiderations, appeals, and peer-to-peer coordination by assembling documentation and helping determine next steps. - Identify recurring payer issues, avoidable denials, missing documentation patterns, and workflow gaps, and share recommendations to improve Mendelia’s processes. Qualifications - 1–5 years of experience in prior authorization, medical billing, revenue cycle, patient access, insurance verification, pharmacy operations, or a related healthcare administrative role. - Working knowledge of health insurance concepts, including benefits, eligibility, medical necessity, coverage criteria, denials, and appeals. - Strong attention to detail and ability to manage multiple cases at once without losing track of deadlines or required documentation. - Excellent written and verbal communication skills, including professional phone etiquette with payers and clinic staff. - Comfort working in payor portals, EHRs, spreadsheets, internal dashboards, and productivity tools. - Ability to learn new payer systems, clinic workflows, and specialty-specific requirements quickly. Preferred Qualifications - Experience with payer portals such as Availity, CoverMyMeds, Carelon, Turning Point, UHC Provider Portal, Cigna, Aetna, or similar systems. - Familiarity with ICD-10, CPT, HCPCS, modifiers, and common clinical documentation requirements. - Experience with surgical, orthopedic, spine, ophthalmology, retina, physical therapy, or specialty medication authorizations. - Experience working with EHRs or practice management systems such as ModMed, AdvancedMD, Athena, Epic, or similar platforms.
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