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UH
Universal Health Solutions
Medical Prior Authorization Specialist
Career Insights for Medical Claims Processor / Representative
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Based on Texas data
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What they do
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.
$45,636 / year median in Texas
-1% projected decline
Job Description
We are hiring an experienced Medical Prior Authorization Specialist for a busy procedural medical office. This position focuses on making sure patients are financially and administratively cleared before scheduled procedures. The person in this role will work directly with insurance companies, authorization portals, referring offices, patients, and our internal clinical and billing teams. Prior medical insurance and authorization experience is required. Primary Responsibilities You will manage the insurance clearance process for assigned patients from start to finish, including: Checking active insurance coverage and plan requirements Reviewing benefits for office visits and scheduled procedures Determining deductible, copay, coinsurance, and estimated patient responsibility Submitting procedure authorization requests through insurance portals or directly to payers Following pending authorizations through approval or denial Obtaining insurance referrals when required Reviewing authorization approvals for correct procedure codes, dates, and services Verifying anesthesia benefits when applicable Contacting patients with estimated procedure costs Collecting payments prior to services when required Arranging payment plans according to office guidelines Communicating with referring offices when additional information or referrals are needed Updating authorization and procedure tracking logs Documenting insurance calls, authorization status, benefits, and patient conversations in the EMR Alerting the appropriate staff when an insurance issue may delay or affect a scheduled procedure Experience We Need Candidates should have previous healthcare experience involving medical insurance and prior authorizations . Experience with the following is especially helpful: Commercial health plans Medicare Insurance authorization websites and payer portals Procedure benefit verification Patient cost estimates Medical referrals eClinicalWorks (eCW) Microsoft Excel Workers' compensation Anesthesia benefit verification Experience working in a procedural specialty such as pain management, orthopedics, surgery, gastroenterology, or an ambulatory surgery setting is a strong plus. Successful Candidates This position is best suited for someone who can manage a high-volume workload without losing track of outstanding items. You should be comfortable calling insurance companies, researching coverage requirements, speaking with patients about money, working authorization queues, and following up repeatedly when necessary. Accuracy and follow-through are extremely important. An authorization request is not considered complete simply because it was submitted; pending cases must be monitored until a determination is received and properly documented. What We Offer Our benefits package includes: Paid holidays Paid time off Competitive pay Opportunities for professional growth