A Medical Claims Processor or Representative reviews and processes medical insurance claims and determines whether an insurance policy will cover a medical procedure. Gathers information from policy holders and organizes insurance files; may process checks with payments to policy holders when a medical claim is approved.
Full-Time (On-site / Hybrid / Remote options) Job Summary We are seeking a detail-oriented and proactive Prior Authorization Specialist to join our team. In this role, you will be responsible for securing insurance approvals for orthopedic procedures, interventional pain management treatments, and physical/occupational therapy plans of care. You will serve as the crucial link between our clinical providers, insurance payers, and patients to ensure timely care delivery and minimize claims denials. Key ResponsibilitiesPrior Authorization & Payer Coordination Submit and track prior authorization requests for orthopedic procedures/imaging/DME, pain management interventions (injections, RFAs, SCS), and PT/OT therapy visit blocks. Review clinical documentation (EHR progress notes, MRI reports, conservative treatment histories) to ensure it meets payer-specific medical necessity criteria. Utilize insurance portals (Availity, NaviNet, Carelon, CoverMyMeds, worker's comp portals) and direct phone channels to monitor status updates. Clinical & Financial Workflow Support Coordinate with orthopedic surgeons, pain management physician, and physical/occupational therapists to obtain missing clinical records or updated Plans of Care (POC). Schedule and facilitate Peer-to-Peer (P2P) reviews between treating providers and insurance medical directors when initial requests are face-to-face denied. Verify patient benefits, co-pays, deductibles, and visit limits for PT/OT services to ensure transparent patient communication. Denials & Appeals Management Identify, investigate, and appeal prior authorization denials in a timely manner. Document all authorization numbers, effective dates, approved unit/visit counts, and notes meticulously within the Electronic Health Record (EHR) system.
Qualifications & SkillsRequired:
Experience:
2+ years of prior authorization experience specifically in Orthopedics, Pain Management, Physical Therapy, or Occupational Therapy .
Coding Knowledge:
Strong understanding of CPT, ICD-10, and HCPCS codes related to musculoskeletal care and rehab therapy units.
Systems:
Proficiency with EHR platforms (e.g., Epic, Eclinical Works, Athena) and major payer portals.
Payer Rules:
Solid understanding of commercial insurance, Medicare/Medicaid guidelines, and Worker's Compensation authorization workflows.
Job Type:
Full-time Pay:
$22.00 - $26.00 per hour
Benefits:
401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance
Experience:
Prior Authorization:
2 years (Required)
Orthopedic :
2 years (Required) pain management: 2 years (Required)
