Overview:

We are seeking a skilled Medical Prior Authorization Specialist to join our team. The ideal candidate will be responsible for obtaining prior authorization for all obstetrical patients, medication authorizations, and medical procedure authorizations from insurance companies. This role involves coordination with various departments, reaching out to insurance providers, gathering, and providing necessary documentation, scheduling peer-to-peer reviews, and meticulously documenting the entire authorization process.

Responsibilities:

1. Initiate and manage the prior authorization process for all obstetrical patients and gynecological patients to include all obstetrical care with delivery, radiology services, consultation referrals, labs, medications, and medical procedures. Primary responsibility will be to enter information on the PRA/SPECT Perinatal Risk Assessment & Single Point Entry Client Tracking for the State of New Jersey. This system will link authorizations and support services to obstetrical patients

2. Communicate effectively with internal departments and insurance companies to obtain necessary authorization

3. Gather and organize patient medical records, treatment plans, and other relevant documentation required for authorization.

4. Ensure all documentation provided meets insurance company requirements and guidelines.

5. Collaborate with providers to obtain additional information or clarification as needed.

6. Schedule and facilitate peer-to-peer reviews between providers and insurance company medical directors.

7. Document all communication and actions taken throughout the authorization process accurately and thoroughly.

8. Monitor the progress of authorization requests and follow up as necessary to expedite approvals.

9. Stay updated on changes in insurance policies, guidelines, and procedures related to prior authorizations.

10. Provide support and guidance to providers and staff regarding prior authorization requirements and processes.

11. Work in a CMA role with patients in various Women's Health departments as needed for additional coverage.

12. Provide any additional support for projects required within the departments.