
Prior Authorization Specialist
3 weeks ago
Blue Health is seeking a Prior Authorization Specialist (also known as Clinical Authorization Coordinator, Pre-Certification Specialist, or Utilization Management Specialist) with a medical or allied health science background (non-clinical role) to support our prior authorization process. This role requires applying clinical knowledge to review, evaluate, and process medical service requests to ensure they meet payer requirements.
Key Responsibilities- Review prior authorization requests for medical services, procedures, and prescriptions.
- Apply clinical knowledge and payer guidelines to assess medical necessity.
- Ensure compliance with HIPAA, CMS, and insurance requirements.
- Coordinate with physicians, pharmacists, and healthcare providers to obtain additional documentation.
- Maintain accurate case records in EMR/EHR systems (Epic, Cerner, Athena).
- Support appeals and denials management when required.
- Background in Nursing, Pharmacy, or Allied Health Sciences (RN, LPN, BSN, PharmD, CPhT, or equivalent).
- Knowledge of ICD-10, CPT, and HCPCS coding systems.
- Strong understanding of medical terminology and payer guidelines.
- Prior experience in utilization management or authorization processes is highly preferred.
- Excellent communication and detail-oriented problem-solving skills.
- Bachelor's degree in Nursing, Pharmacy, Allied Health, or equivalent clinical field.
- Preferred MBBS, DPT, PharmD
- Ability to work independently in a fast-paced environment.
- Familiarity with EHR/EMR systems and insurance workflows.
- Entry level
- Full-time
- Health Care Provider
- IT Services and IT Consulting
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