Prior Authorization Specialist

Prior Authorization Specialist Madison Medical & Sports Rehabilitation Center — Madison, NJ 07940 About Madison Medical Madison Medical is a physician-led, multidisciplinary ambulatory care facility delivering out-of-network care across sports medicine, medical wellness, and rehabilitation. Based in Madison, New Jersey, we operate as a licensed multi-specialty musculoskeletal super group with a vertically integrated care model designed to deliver the full continuum of MSK and wellness services under one roof. Our clinical and operational structure reflects the infrastructure of a hospital-based outpatient center, with greater agility, stronger patient experience, and a sharper operational focus. We combine clinical excellence, structured systems, and modern technology to support high-level patient care across every stage of the patient journey. Our practice operates from multiple floors of dedicated clinical space at 345 Main Street, Madison, NJ, with active buildout underway to expand advanced recovery, regenerative medicine, and wellness services. We are also building Management Services Organization infrastructure to support future multi-site expansion. Our service lines span more than 15 specialties, including chiropractic medicine, interventional pain management, physical therapy and rehabilitation, primary care and sports medicine, podiatry, acupuncture, allergy testing and SLIT immunotherapy, hormone optimization, weight management, regenerative medicine, IV nutrient therapy, sleep medicine, athletic recovery, behavioral health integration, and telehealth. Position Summary We are seeking a detail-oriented and experienced Prior Authorization Specialist to join our Revenue Cycle Management team. This position is available as either part-time or full-time depending on the candidate's availability and practice needs. You will be responsible for obtaining, tracking, and managing prior authorizations and pre-certifications for medical services, procedures, medications, and durable medical equipment across our multidisciplinary practice. Responsibilities Authorization Management —

Services & Procedures:

Initiate, submit, and follow up on prior authorization and pre-certification requests for all services including office visits, diagnostic imaging (MRI, CT, X-ray), physical therapy, chiropractic, acupuncture, podiatric procedures, interventional pain management, injections, and DME Verify insurance eligibility and benefits using payer portals (Availity, NaviNet, Evicore, CareCore) and direct payer phone lines Obtain and document authorization numbers, effective dates, approved units/visits, and any payer-imposed limitations Track all open, pending, approved, denied, and expiring authorizations in our EHR system and internal tracking tools Proactively monitor expiration dates and initiate re-authorizations to prevent coverage lapses Authorization Management —

Medications & Pharmacy:

Submit and manage prior authorizations for prescribed medications including specialty drugs, injectables, compound medications, and controlled substances when required by payers Coordinate with prescribing providers to obtain supporting clinical documentation, diagnosis justification, and step therapy or formulary exception information Track medication authorization requests from submission through determination, documenting approval, denial, or pending status with all relevant reference numbers and timelines Communicate with pharmacies and pharmacy benefit managers (PBMs) to resolve medication authorization holds and ensure timely patient access Notify patients and providers of medication authorization outcomes including any alternative therapy requirements or appeal options

Denial Management & Appeals:

Proactively track and log all authorization denials including denial reason codes, payer rationale, and clinical justification cited by the payer Maintain a detailed denial tracking log categorized by denial type (medical necessity, missing information, out-of-network, formulary/step therapy, untimely filing, etc.) Identify denial trends and patterns by payer, service type, provider, and reason code, and report findings to leadership with actionable recommendations Submit peer-to-peer review requests and coordinate provider availability for payer-initiated clinical reviews Prepare and submit formal written appeals with supporting clinical documentation, letters of medical necessity, and relevant medical records within payer-required timeframes Track appeal outcomes and maintain records of overturn rates by payer and denial category Escalate unresolved or recurring denial issues to the RCM Supervisor and COO for strategic payer follow-up

Information Requests & Documentation Coordination:

Proactively manage and respond to payer requests for additional information (RFIs) including clinical notes, lab results, imaging reports, and letters of medical necessity Track all inbound information requests with due dates and ensure timely submission to prevent authorization delays or auto-denials Communicate with providers and clinical staff to obtain required documentation quickly and accurately Coordinate with referring physicians' offices to ensure referral documentation is complete and authorization-ready Collaborate with the front desk and scheduling teams to ensure patients are not scheduled for services without active, valid authorizations Notify patients of authorization status, delays, and any out-of-pocket implications

Revenue Cycle Support:

Assist the billing team with resolving authorization-related claim denials and resubmissions Participate in RCM team meetings and contribute to KPI reporting on turnaround times, denial rates, approval percentages, and appeal outcomes Stay current on changes to payer authorization requirements, NJ Medicare, Tricare & Commercial Payer guidelines, commercial plan policies, and pharmacy benefit updates

Compliance:

Maintain strict HIPAA compliance when handling protected health information Adhere to all applicable federal, state, and payer-specific regulations governing prior authorization processes Qualifications Minimum 2 years of experience in prior authorization, insurance verification, or medical billing/coding in a healthcare setting High school diploma or GED required; associate degree in healthcare administration or related field preferred Proficient in payer and medication authorization platforms including Availity, NaviNet, Evicore/CareCore, CoverMyMeds, and Surescripts. Familiarity with ICD-10-CM and CPT coding conventions as they relate to authorization requirements Experience with medication prior authorizations including specialty drugs, PBM portals, and formulary navigation Proficiency with EHR/practice management systems (CureMD experience is a plus) Strong computer skills including Microsoft Office (Outlook, Excel, Word, Teams) Excellent verbal and written communication skills Ability to manage a high volume of concurrent authorization requests with strong attention to detail Preferred Qualifications Experience in a multidisciplinary outpatient or physician practice setting Experience with institutional billing (UB-04) and facility-based authorizations Knowledge of NJ-specific insurance regulations, NJ FamilyCare/Medicaid managed care plans, and state surprise billing protections Experience building or maintaining denial tracking systems and reporting dashboards What We Offer Competitive hourly pay: $19.00-$25.00/hour depending on experience Health insurance (Horizon Blue Cross Blue Shield) after 60 days (full-time employees) Dental and vision coverage (MetLife) after 60 days (full-time employees) 401(k) retirement plan (Merrill Lynch) after one year of service Paid time off and NJ Earned Sick Leave Supportive team environment with real growth opportunities into senior RCM, credentialing, compliance, or operations roles Professional development support including certification assistance Schedule & Location Part-time or full-time availability considered Monday through Friday; hours based on role structure Full-time schedule: 8:30 AM - 5:00 PM - Subject to adjustment based on practice requirements On-site at 345 Main Street, Madison, NJ 07940

Pay:

$22.00 - $26.00 per hour

Work Location:

In person