GAP Exceptions/Authorizations Specialist

Job Duties and Responsibilities:

Gap Exception & Network Exception Management

• Research payer-specific requirements for gap exceptions, network exceptions, and single case agreements.


• Submit gap exception and network exception requests through payer portals, fax, and telephonic channels.


• Coordinate with provider offices to obtain required clinical and supporting documentation.


• Monitor request status and conduct timely follow-up activities to ensure prompt resolution.


• Document all payer interactions, reference numbers, and outcomes accurately in designated tracking systems.


• Escalate reimbursement barriers and complex cases to leadership or client-designated escalation channels when necessary.

Prior Authorization Management

• Review insurance benefits and determine authorization requirements based on payer guidelines.


• Prepare and submit prior authorization requests for prescribed therapies and services.


• Obtain and track payer decisions, including approvals, denials, and pending determinations.


• Follow up proactively on pending cases to prevent delays in treatment initiation.


• Coordinate with provider offices to secure additional clinical documentation required by payers.


• Maintain detailed documentation of authorization outcomes and payer communications.

Referral Coordination

• Process PCP and specialty referrals required by HMO and managed care plans.


• Verify referral requirements and ensure submission of complete and accurate information.


• Track referral requests through completion and communicate updates to providers and internal stakeholders.

Stakeholder Communication

• Serve as a reimbursement support resource for assigned Territory Managers and provider offices.


• Provide timely updates regarding authorization status, reimbursement barriers, and patient access challenges.


• Maintain strong working relationships with healthcare providers, insurance carriers, and internal teams.

Documentation & Compliance

• Maintain accurate patient records and reimbursement documentation in compliance with HIPAA standards.


• Ensure all activities meet client, payer, and organizational quality standards.


• Adhere to turnaround-time expectations, SLAs, and productivity requirements.

Qualifications

Required

• 2-3+ years of healthcare reimbursement, prior authorization, insurance verification, or insurance operations experience.


• Strong knowledge of commercial, Medicare, Medicaid, HMO, and PPO insurance plans.


• Experience working with payer portals and telephonic payer outreach.


• Understanding of prior authorization, referral, appeal, and reimbursement workflows.


• Strong attention to detail and excellent organizational skills.


• Effective verbal and written communication skills.

Preferred

• Experience supporting specialty medications, medical devices, diabetes, endocrinology, or DME programs.


• Experience with Availity, PVerify, Salesforce, or similar reimbursement platforms.


• Knowledge of gap exceptions, single case agreements, and network exception processes.


• Experience collaborating with Territory Managers, field reimbursement teams, or provider offices.