Clinical Prior Authorization Specialist

Summary

Join Heartbeat Health, a health tech startup revolutionizing cardiovascular care, as a Clinical Prior Authorization Specialist! You will play a crucial role in ensuring timely and accurate processing of prior authorizations for medical services. This involves coordinating and obtaining authorizations, reviewing clinical documentation, communicating with providers and patients, and documenting all activities in the EHR. You will also monitor pending authorizations, handle appeals, and track key metrics. The position requires a minimum of 2 years of relevant experience and strong clinical knowledge. You will work 9 am to 5 pm CST.

Requirements

• Minimum 2 years of prior authorization, utilization management, case management, or related healthcare experience
• Exceptional people skills and a GREAT communicator
• Strong clinical knowledge, attention to detail, and the ability to communicate effectively with healthcare providers, payers, and patients to ensure timely and accurate processing of authorizations
• Familiarity with payer portals, ICD-10, CPT, and HCPCS coding
• A team player with a high level of independence and proactivity
• Detail-oriented with a focus on processes
• Fast learner while being flexible and adaptable
• Outstanding organizational and multitasking abilities
• Self-driven and excited to support new technology

Responsibilities

• Coordinate and obtain prior authorizations for medical services, diagnostic tests, procedures, and medications
• Review clinical documentation to determine medical necessity and payer requirements for prior authorizations
• Communicate with providers and clinical staff to gather additional information as needed for approval
• Document all authorization activities and payer communications in the electronic health record (EHR)
• Monitor pending authorizations and follow up to ensure timely approvals
• Notify providers and patients of authorization outcomes, including any denials or required appeals
• Collaborate with billing and scheduling teams to ensure authorization requirements are met before services are rendered
• Maintain up-to-date knowledge of payer rules, medical necessity criteria, and regulatory changes
• Assist with appeals processes when prior authorizations are denied
• Track and report authorization metrics, turnaround times, and approval rates
• Reduce delays in care, improve patient experience, and support Heartbeat’s revenue cycle