Prior Authorization Clerk

Prior Authorization Clerk

Position Summary

The Prior Authorization Clerk is responsible for obtaining, coordinating, and documenting insurance prior authorizations and pre-certifications for hospital and clinic services to ensure timely patient access to care and appropriate reimbursement. This position works collaboratively with providers, clinical staff, scheduling personnel, patients, and insurance carriers to secure approvals for services requiring authorization. The Prior Authorization Clerk supports revenue cycle integrity, minimizes authorization-related denials, and contributes to a positive patient experience within the Critical Access Hospital setting.

Key Responsibilities

• Review scheduled services and determine prior authorization, pre-certification, or referral requirements based on payer guidelines.
• Obtain and submit authorizations for inpatient, outpatient, diagnostic, therapeutic, and specialty services.
• Gather and submit supporting clinical documentation required for medical necessity review.
• Monitor authorization requests and proactively follow up with insurance carriers to ensure timely determinations.
• Accurately document authorization status, approval numbers, denials, and related correspondence within the electronic health record (EHR) and applicable systems.
• Verify patient insurance eligibility, benefits, and coverage requirements as needed.
• Communicate authorization status, payer requirements, and service limitations to providers, scheduling staff, and patients.
• Collaborate with clinical, registration, scheduling, and billing teams to resolve authorization issues and prevent reimbursement delays.
• Assist with researching and addressing authorization-related claim denials and appeals.
• Educate patients regarding authorization requirements and potential financial implications of services.
• Maintain compliance with HIPAA, payer regulations, and hospital policies and procedures.
• Participate in quality improvement initiatives and process enhancement efforts related to patient access and reimbursement.
• Maintain confidentiality of patient information and sensitive data.
• Perform other duties as assigned to support departmental and organizational goals.

Qualifications

• High school diploma or equivalent required.
• Minimum one (1) year of experience in healthcare, medical office operations, patient access, insurance verification, scheduling, billing, or a related field.
• Strong organizational skills with the ability to manage multiple priorities and meet deadlines.
• Excellent customer service, communication, and interpersonal skills.
• Proficiency with Microsoft Office applications and electronic health record (EHR) systems.
• Ability to analyze and interpret insurance requirements and payer guidelines.
• Knowledge of HIPAA regulations and patient confidentiality requirements.
• Ability to work independently while maintaining effective collaboration with interdisciplinary teams.

Preferred Qualifications

• Associate degree in Healthcare Administration, Business, Medical Office Administration, or a related field.
• Prior experience obtaining insurance authorizations or working within revenue cycle operations.
• Knowledge of Medicare, Medicaid, commercial insurance plans, managed care, and payer authorization requirements.
• Familiarity with medical terminology, ICD-10 diagnosis coding, CPT coding, and reimbursement processes.
• Experience working in a Critical Access Hospital, rural healthcare organization, or multi-specialty clinic environment.
• Experience with denial prevention, appeals, and revenue cycle performance improvement initiatives.
• Certification related to healthcare access, revenue cycle, or medical office administration preferred.

EOE