Authorization Specialist

Published: 6/14/2022

Education

Job Description

Department: Neurology
Reports To: Practice Manager / Office Manager
Employment Type: Full-Time, IN-PERSON
Location: Oakland Neurology Center

Position Summary:

The Prior Authorization Specialist is responsible for obtaining, coordinating, and tracking insurance authorizations for neurological services, diagnostic testing, medications, and procedures. This position works closely with neurologists, advanced practice providers, clinical staff, patients, pharmacies, imaging centers, and insurance companies to ensure that required authorizations are obtained accurately and in a timely manner.

The ideal candidate has strong organizational skills, attention to detail, knowledge of insurance authorization requirements, and the ability to manage multiple requests while supporting efficient patient care in a busy neurology practice.

Essential Duties and Responsibilities-

Prior Authorizations and Insurance Coordination

Obtain prior authorizations for neurological services, diagnostic testing, procedures, and medications as required by individual insurance plans.
Verify patient insurance eligibility, benefits, coverage limitations, and authorization requirements.
Submit authorization requests through insurance company portals, telephone, fax, and electronic health record (EHR) systems.
Review provider orders, clinical notes, diagnosis codes, procedure codes, and supporting documentation to ensure complete and accurate submissions.
Track authorization requests from initial submission through approval, denial, or appeal.
Follow up with insurance companies on pending requests and communicate delays or additional documentation requirements to the appropriate staff.
Maintain accurate records of authorization numbers, approval dates, expiration dates, approved visits, and service limitations.
Monitor authorization expiration dates and initiate renewals when necessary.
Communicate authorization status to providers, clinical staff, scheduling personnel, and patients as appropriate.

Neurology-Specific Authorizations

Obtain authorizations for neurological diagnostic testing, including:
- Electroencephalograms (EEGs) and ambulatory EEG monitoring.
- Electromyography (EMG) and nerve conduction studies (NCS).
- Magnetic resonance imaging (MRI) and computed tomography (CT) scans when ordered by neurology providers.
- Other neurological diagnostic studies and procedures performed or ordered by the practice.
Coordinate authorizations for specialty medications and treatments, including migraine therapies, injectable medications, infusion treatments, and other neurologic therapies requiring payer approval.
Assist with authorizations for medications used to treat epilepsy, multiple sclerosis, Parkinson's disease, migraine, neuropathy, and other neurological conditions when required.
Coordinate medication authorizations with pharmacies, specialty pharmacies, infusion centers, and insurance representatives.
Assist with authorization requests for botulinum toxin injections, including Botox for chronic migraine, when applicable.
Process initial and renewal authorizations for specialty treatments according to payer-specific requirements.
Confirm that requested services, medication quantities, treatment frequencies, and approved units align with payer authorization guidelines.

Denials and Appeals

Review authorization denials and identify the reason for denial.
Coordinate with providers and clinical staff to obtain additional medical records, clinical notes, test results, and supporting documentation.
Prepare and submit reconsiderations or appeals according to insurance company guidelines.
Coordinate peer-to-peer review requests between providers and insurance medical directors when necessary.
Track appeal deadlines and follow up on outstanding decisions.
Escalate urgent or time-sensitive authorization issues to the appropriate provider or manager.

Documentation and Administrative Responsibilities

Maintain thorough documentation of authorization activity in the EHR and designated tracking systems.
Communicate promptly with scheduling staff regarding authorization approvals, denials, and outstanding requests.
Help prevent avoidable appointment cancellations, treatment delays, and claim denials by identifying authorization requirements before services are provided.
Protect confidential patient information and comply with HIPAA regulations and practice policies.
Stay current with insurance payer policies, medical necessity criteria, and authorization procedures relevant to neurology.
Perform additional administrative duties as assigned.

Qualifications and Requirements

High school diploma or equivalent required.
Previous experience in a medical office, prior authorization, insurance verification, referrals, or healthcare administration preferred.
Neurology experience preferred but not required.
Knowledge of medical terminology and insurance authorization processes.
Familiarity with ICD-10 diagnosis codes and CPT/HCPCS procedure codes preferred.
Experience with electronic health records, insurance portals, and specialty medication authorization systems preferred.
Understanding of commercial insurance, Medicare, Medicaid, and managed care requirements.
Strong organizational skills and the ability to manage multiple requests and deadlines.
Excellent written and verbal communication skills.
Ability to communicate professionally with providers, patients, pharmacies, and insurance representatives.
Strong problem-solving skills and attention to detail.
Ability to work independently while collaborating effectively with clinical and administrative teams.
Commitment to patient confidentiality and accurate documentation.

Key Performance Expectations

Submit complete and accurate authorization requests within established time frames.
Follow up consistently on pending requests to minimize delays in patient care.
Maintain accurate authorization records and monitor approval expiration dates.
Communicate authorization status and potential barriers to treatment promptly.
Support timely access to neurological testing, medications, and procedures.
Identify and escalate denials, urgent requests, and authorization issues appropriately.
Maintain compliance with payer requirements, privacy regulations, and office procedures.

Work Environment

This position operates in an outpatient neurology office and involves frequent computer use, telephone communication, insurance portal navigation, and coordination with clinical staff and external healthcare organizations. The role requires the ability to manage competing priorities while maintaining accuracy and professionalism.

Equal Employment Opportunity:

Oakland Neurology Center is an equal opportunity employer committed to providing a professional, respectful, and inclusive workplace.

Disclaimer:

This job description describes the general responsibilities and qualifications of the position and is not intended to include every duty that may be assigned. Responsibilities may change based on the needs of the practice.

\nCompany Description

Oakland Neurology Center is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We are dedicated to providing exceptional healthcare services to our community. Our team of professionals is committed to creating a welcoming environment for our patients. We are currently seeking a motivated and compassionate Medical Assistant to join our team.