Prior Authorization Specialist

Job Title: Prior Authorization Specialist

Reports to: Office Manager

Supervises: n/a

Department: Clinical

Location: Grandville

Employment Status: Part-time

Job Summary:  The Prior Authorization (PA) Specialist works to obtain approval from insurance companies for procedures, treatments and medications for West Michigan Dermatology patients.  This includes initiating the PA process and following it through till approval is obtained – submitting appeals when needed.

Job Duties and Functions:

• Collects patient demographic and insurance information verifying that reimbursement criteria are present.


• Navigates complexities with insurance companies and pharmacies in order to obtain prior authorizations in a timely fashion. Appeals these decisions if needed.


• Keeps up with drug manufacturer recommendations, formulary changes, claim denials, and any other relevant information specific to biologic medications maintained on site.


• Utilizes EMR to update patient record meticulously with the status of the PA.


• Possesses a strong knowledge base with regard to insurance requirements as well as billing authorization requirements.


• Is able to provide patient education and communication on the status of their PA that is detailed and accurate.


• Remains current on the latest developments with insurance coverage and denials.


• Other duties as directed by the site manager and providers.

Knowledge/Skills/Abilities:

• 3+ years of experience in a medical office working with insurance and authorization processes.


• Knowledge of medical terminology, ICD10 codes, and HIPAA regulations.


• Skilled in using various computer programs and applications especially word processing and EMR.


• Meticulous documentation skills in addition to a high level of attention to detail.


• Ability to multi task and work efficiently under pressure.


• Must be computer literate with the ability to work with various computer systems such as EMR, word-processing and project management programs.


• Ability to communicate clearly and concisely using excellent grammar and punctuation in all written correspondence.


• Ability to establish and maintain positive relationships with employees, physicians, and management.

Environmental Working Conditions:

Must be able to work in an office environment and sit at a desk for an extended period of time.  Must be able to work on a computer for 3-4 hours at a time. 

Physical Requirements:

• Physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. The employee is occasionally required to stand; walk; sit; use hands to finger; handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, and the ability to focus. Requires visual acuity and normal color perception.

 HIPAA/PHI Security Level: HIGH (Low, Medium, or High)

Indicate the security access level of Protected Health Information (PHI) as necessary to perform essential key responsibilities of the position (access, utilize, disclose, store, and/ or dispose of PHI).

1. Low –information access is of general nature representing summary type data rather than specific identifiable demographic or sensitive data.


2. Medium – information access is specific to an individual’s demographics and service information (type of service, services received, dates of service, and provider of service).


3. High – information access is detailed and sensitive to an individual’s demographics, service information, and personal medical history (past/present medical conditions, specifics of medical diagnosis or tests, treatment plans, and family history).

We offer:

• Competitive compensation


• Health dental, vision benefits for full time employees


• Retirement package


• PTO accrual and holiday benefits


• Employee discounts on products and services


• An environment that encourages employees to be high performance and to grow within the organization.

Special note: Due to the unique operational needs of our clinics, we may request that our employees work in a different site from the one they were originally scheduled in.  Sometimes these requests are planned and sometimes they are spontaneous and could be after the employee has reported to work for the day.  Reasons for these requests vary but they are mainly is to ensure coverage in case of high patient volume, unscheduled absences from other staff, etc.  Therefore, we require all our employees to have a valid and unrestricted driver’s license.  Mileage reimbursement will be paid in accordance with our Mileage Reimbursement Policy.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.