Prior Authorization Appeals Specialist

Job Summary

Working remotely, the full-time Prior Authorization Appeals Specialist will manage pre-service authorization denials and appeals, navigate payer requirements, and coordinate clinical documentation to ensure patient access to medically necessary therapies.

Key responsibilities

• Review and manage denials and appeals, coordinating reconsiderations and peer-to-peer reviews within required timeframes
• Interpret payer policies and medical necessity criteria to determine resolution pathways for complex cases
• Collaborate with providers and internal teams to gather necessary documentation for appeals and communicate outcomes effectively

Required qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree preferred
• 3-5 years of experience in prior authorization, denial management, or appeals within the healthcare sector
• Demonstrated experience managing complex authorization or denial-related cases across multiple payer types
• Strong understanding of commercial and government payer requirements, including Medicare and Medicaid
• Proficiency with EMR systems, payer portals, and Microsoft Office applications