Prior Authorization Specialist

3 weeks ago


Lahore, Punjab, Pakistan Blue Health Full time
Prior Authorization Specialist / Clinical Authorization Coordinator (Medical / Allied Health Background)

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.
Requirements
  • 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.
Qualifications
  • 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.
Seniority level
  • Entry level
Employment type
  • Full-time
Job function
  • Health Care Provider
Industries
  • IT Services and IT Consulting
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