Prior Authorization Specialist

Benefits We offer a comprehensive benefits package, including: 401(k) with company match Medical Insurance Dental Insurance Vision Insurance Life Insurance Options Flexible Spending Account (FSA) Health Savings Account (HSA) Paid Time Off (PTO) Sick Time - 40 Hours through accrual Paid Holidays Career Growth Opportunities Position Overview We are seeking a highly motivated, detail-oriented Prior Authorization Specialist to join our growing team. This position will focus on obtaining insurance approvals for specialty medications, biologics, and infusion therapies while providing exceptional support to patients, providers, pharmacies, and insurance companies.

The ideal candidate will possess strong insurance knowledge, excellent communication skills, exceptional organizational abilities, and a commitment to helping patients gain access to medically necessary treatments. A positive attitude and strong work ethic are essential for success in this role. Primary Responsibilities - Home Biologics Prior Authorization Specialist This role is responsible for managing the entire prior authorization process for self-administered specialty medications, including but not limited to: Humira Enbrel Cosentyx Skyrizi Stelara Rinvoq Xeljanz Other specialty biologic and immunology therapies Prior Authorization Management Review patient insurance benefits and coverage requirements. Prepare and submit prior authorization requests to commercial, Medicare, Medicaid, and other insurance carriers. Gather and organize clinical documentation necessary for authorization approvals. Work closely with physicians and clinical staff to obtain supporting medical records and documentation. Monitor authorization status and proactively follow up with insurance companies to prevent delays. Appeals and Denial Management Review denied authorization requests and determine next steps. Prepare and submit first-level and second-level appeals. Coordinate peer-to-peer reviews when required. Compile supporting clinical information to strengthen appeal submissions. Track appeal outcomes and maintain accurate documentation. Copay Assistance & Patient Assistance Programs Enroll eligible patients into manufacturer copay assistance programs and copay cards. Educate patients regarding available financial assistance options. Identify patients with high out-of-pocket costs and assist with enrollment into manufacturer patient assistance programs (PAPs). Complete and submit all required patient assistance applications and supporting documentation. Monitor application status and communicate updates to patients and providers. Pharmacy Coordination Coordinate with specialty pharmacies regarding prescription processing and fulfillment. Follow up on prescription status, shipment scheduling, and patient onboarding. Troubleshoot issues that may delay medication delivery. Assist patients experiencing difficulties obtaining medications through specialty pharmacies. Communicate approvals, denials, shipment updates, and treatment initiation timelines to patients. Patient Communication Notify patients of insurance approvals and next steps. Provide ongoing support throughout the authorization and medication fulfillment process. Answer questions regarding insurance coverage, copays, financial assistance, and specialty pharmacy requirements. Maintain compassionate and professional communication with patients at all times.

Infusion / Office

Injectable Prior Authorization Specialist We are also seeking candidates experienced in obtaining authorizations for physician-administered and infusion-based therapies.

Responsibilities Include:

Verification of Benefits (VOB) Conduct detailed insurance verification and benefit investigations for office-administered medications. Determine patient financial responsibility including deductibles, coinsurance, copays, and out-of-pocket obligations. Review medical and pharmacy benefit coverage. Identify payer-specific authorization requirements and coverage limitations. Prior Authorization Submission Prepare and submit authorization requests for infusion and office-administered medications. Collect and organize supporting clinical documentation. Track authorization status and ensure approvals are secured before scheduled treatment dates. Maintain accurate records within practice management and EMR systems. Appeals and Denial Resolution Investigate denied authorization requests. Prepare comprehensive appeal packages with supporting clinical documentation. Coordinate peer-to-peer reviews and additional documentation requests. Follow appeals through final determination. Financial Assistance & Copay Support Enroll eligible patients in manufacturer copay assistance programs. Review patient financial obligations before treatment administration. Discuss anticipated treatment costs with patients in a professional and compassionate manner. Assist patients with high out-of-pocket expenses by identifying and applying for available patient assistance programs. Monitor approval status and communicate outcomes to patients. Medication Procurement Coordinate medication ordering through specialty pharmacies and approved distributors. Ensure medications are ordered and delivered in advance of scheduled appointments. Verify authorization approvals before medication ordering. Track medication shipments and maintain communication with vendors and pharmacies. Resolve procurement delays to prevent treatment interruptions. Required High school diploma or equivalent. Experience with specialty medications and biologic therapies. Strong understanding of prior authorization processes and insurance requirements. Excellent verbal and written communication skills. Strong organizational and time-management abilities. Ideal Candidate The ideal candidate is someone who: Maintains a positive attitude even in challenging situations. Demonstrates a strong work ethic and commitment to patient care. Takes ownership of responsibilities and follows tasks through completion. Works effectively both independently and as part of a team. Possesses excellent problem-solving skills. Is highly detail-oriented and organized. Delivers exceptional customer service to patients, providers, pharmacies, and insurance representatives.

Pay:

$19.00 - $20.00 per hour

Benefits:

401(k) Health insurance Paid time off

Work Location:

In person