Find & Apply For Insurance Claims / Policy Clerk Jobs in Corte Madera, California

We are seeking an experienced and detail-oriented Prior Authorization Specialist to manage insurance authorization processes for medications, biologics, radiology services, diagnostic testing, and medical procedures. This role serves as a critical liaison between providers, patients, pharmacies, payers, and clinical staff to ensure timely approval of medically necessary services while minimizing delays in patient care. The ideal candidate has a strong understanding of payer requirements, medical necessity criteria, and authorization workflows. They are highly organized, proactive, and committed to delivering exceptional patient service while ensuring compliance with regulatory and payer requirements. Core Responsibilities Medication, Biologic & Specialty Therapy Authorizations Submit and manage prior authorization requests for prescription medications and specialty medications. Infusion therapies and biologic treatments, as needed. Review clinical documentation to ensure completeness and medical necessity requirements are met before submission. Coordinate with providers, nursing staff, specialty pharmacies, infusion centers, and insurance carriers to obtain authorization approvals. Monitor authorization status and proactively follow up on pending requests to prevent treatment delays. Assist with renewal authorizations for ongoing biologic and specialty medication therapies. Support benefits investigations, site-of-care reviews, payer restrictions, and specialty pharmacy requirements. Prepare and coordinate appeals, reconsiderations, peer-to-peer review requests, and supporting documentation for denied medication authorizations. Radiology, Diagnostic & Procedure Authorizations Obtain prior authorizations and pre-certifications for diagnostic imaging services, including MRI, CT, ultrasound, PET scans, and other advanced diagnostic studies. Secure insurance authorizations for office-based procedures, endoscopic procedures, surgical services, infusion treatments, and ancillary healthcare services. Verify insurance eligibility, benefits, coverage limitations, and authorization requirements before services are scheduled. Ensure all required clinical documentation, provider notes, and supporting medical records are submitted accurately and within payer deadlines. Collaborate with providers, clinical staff, scheduling teams, and payers to ensure services are authorized and scheduled in a timely manner. Document authorization determinations, authorization numbers, approval dates, and authorization periods within the electronic medical record and practice management systems. Denial Management & Appeals Review authorization denials and determine appropriate next steps for resolution. Prepare appeal packets and supporting clinical documentation to overturn adverse determinations. Coordinate peer-to-peer review requests between providers and health plans when applicable. Track appeal outcomes and identify trends that may improve future authorization success rates. Patient Advocacy & Communication Serve as a resource for patients regarding authorization requirements, insurance processes, and coverage determinations. Communicate authorization status updates to patients in a professional, compassionate, and timely manner. Assist patients in understanding payer requirements, appeal options, and potential financial implications of services. Work collaboratively with patients to reduce barriers to care and facilitate timely treatment. Cross-Functional Coverage & Team Collaboration Provide cross-coverage for medication, biologic, radiology, and procedural authorization workflows as operational needs require. Collaborate closely with providers, nurses, medical assistants, scheduling staff, pharmacies, infusion centers, and insurance carriers. Support continuity of care by ensuring authorization responsibilities are maintained during staff absences, vacations, and periods of increased workload. Compliance & Operational Excellence Maintain current knowledge of payer policies, medical necessity guidelines, specialty medication requirements, and regulatory standards. Ensure compliance with payer requirements, HIPAA regulations, and organizational policies. Identify workflow improvement opportunities to reduce authorization turnaround times and improve approval rates. Participate in quality improvement initiatives related to authorization management and patient access. Required Experience Minimum of 2-3 years of experience in healthcare prior authorizations, insurance verification, utilization management, revenue cycle operations, or medical office administration. Demonstrated experience obtaining medication, biologic, radiology, diagnostic, and procedural authorizations. Strong understanding of commercial, Medicare, Medicaid, and managed care insurance plans. Experience working with electronic medical records (EMR), practice management systems, and payer authorization portals. Epic experience a plus! Knowledge of medical terminology, clinical documentation requirements, and medical necessity guidelines. Experience with insurance denials, appeals, reconsiderations, and peer-to-peer review processes. Preferred Qualifications Experience in gastroenterology, ambulatory surgery, infusion services, or specialty medicine strongly preferred. Familiarity with biologic therapies, infusion medications, specialty pharmacy processes, and medication assistance programs. Experience with endoscopy, radiology, infusion, and specialty medication authorization workflows. Certified Medical Administrative Assistant (CMAA), Certified Professional Biller (CPB), or similar healthcare certification preferred but not required. Professional Skills Exceptional attention to detail and organizational skills. Strong analytical and problem-solving abilities. Excellent verbal and written communication skills. Ability to manage multiple priorities and meet deadlines in a fast-paced healthcare environment. Strong customer service skills with a patient-centered approach. Proficiency with EMR systems, payer portals, Microsoft Office applications, and healthcare technology platforms. Personal Attributes The ideal candidate is: Patient-focused and committed to reducing barriers to care. Persistent and resourceful when navigating complex payer requirements. Calm and professional when managing high volumes of requests and competing priorities. Collaborative and supportive of team-based patient care. Flexible and willing to provide cross-functional support across medication, biologic, radiology, and procedural authorization workflows. Proactive in identifying solutions and improving operational efficiency. Compensation This is a full-time position (40 hours/week) with a competitive rate $28-33/HR, depending on experience, demonstrated expertise in prior authorizations, denial management, payer relations, and specialty healthcare operations. Opportunities for growth and merit-based increases are available as responsibilities expand. Benefits Work Arrangement Hybrid flexibility available following successful completion of training and onboarding. Health & Insurance Medical Insurance with multiple plan options Dental Insurance Vision Insurance Short-Term Disability (STD) Long-Term Disability (LTD) Life Insurance Time Off Paid Time Off (PTO) Paid Sick Leave Paid Holidays Well-Being & Professional Development Wellness Reimbursement Program Employee Assistance Program (EAP) Professional Development and Continuing Education Support Certification and training reimbursement opportunities

Job Type:

Full-time Pay:

$28.00 - $33.00 per hour Expected hours: 8.0 per week

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

In person