Senior Authorization Specialist

Care Options for Kids connects leading pediatric specialists with families to provide best-in-class pediatric therapy, nursing, and school-based services. We seamlessly integrate into children’s lives by bringing individualized care to children where they live, work, and play.

Our pediatric specialists are committed to providing high-quality pediatric services that help children and families live their best lives. We empower our community of clinicians to meet children where they are by providing the support and resources necessary to decrease administrative burdens. This focus allows our clinicians to obtain optimal work-life balance.

Senior Authorizations Specialist
Position Summary:
The Senior Associate role serves as a subject matter expert and escalation point within the revenue cycle team. This role requires advanced knowledge of revenue cycle operations, independent problem-solving, and a proactive, solution-oriented mindset. This position requires ownership of complex cases, drives resolution strategies, and delivers exceptional service to both internal and external stakeholders. This position is ideal for a seasoned professional who thrives in a fast-paced, collaborative environment and is committed to continuous improvement and operational excellence.

Key Responsibilities:

• Obtain prior authorizations and pre-certifications for in-home nursing services for a dedicated caseload of pediatric clients.
• Verify insurance benefits, coverage limitations, and authorization requirements for Medicaid, managed Medicaid, commercial and federal plans.
• Submit complete and accurate authorization requests through payer portals, phone, or fax.
• Track authorization status and follow up with payers to ensure timely approvals.
• Request, negotiate and complete single case agreements and letter agreements.
• Communicate authorization determinations, requirements, and delays to providers, scheduling teams, and patients.
• Review clinical documentation to ensure it meets payer medical necessity criteria.
• Identify and escalate authorization denials or delays for appeal or peer-to-peer review.
• Maintain accurate records of authorization activity in company EMR systems.
• Track authorization-related denial trends and escalate recurring payer issues.
• Stay current on payer policies, authorization rules, state and federal regulations, and out-of-network reimbursement rules.
• Support denial prevention initiatives and revenue cycle performance improvement efforts.

Note: All roles include administrative tasks that support core revenue cycle outcomes.

Education, Experience, and Competencies:

· Minimum 3 years of experience in healthcare revenue cycle management, with a focus on billing, A/R, or authorizations.

• Experience with private duty nursing authorizations
• Pennsylvania Medicaid experience

· Demonstrated success in resolving complex RCM issues independently.

· High school diploma or GED required; associate or bachelor’s degree preferred.

· Advanced proficiency with EMR systems, payer portals, and Microsoft Office tools.

· Strong understanding of payer policies, coding, and reimbursement methodologies.

· Exceptional communication and customer service skills, with the ability to de-escalate and resolve sensitive issues.

· Proven ability to manage competing priorities and meet deadlines in a remote work environment.

General Duties and Responsibilities:

· General understanding of the departments and functions across the organization, especially those that interlock workflow with RCM) in order to assist and direct possible issues to the appropriate department or expertise when needed.

· Manage and resolve high-complexity revenue cycle issues, including escalated claims, denials, and payer disputes.

· Independently analyze and troubleshoot systemic issues impacting billing, collections, or authorizations.

· Serve as a resource and mentor to junior associates, providing guidance on best practices and complex scenarios.

· Collaborate cross-functionally with clinical, operational, and technical teams to streamline workflows and improve outcomes.

· Identify and implement process improvements that enhance efficiency, accuracy, and compliance.

· Maintain detailed documentation of actions taken and outcomes achieved in EMR and other systems.

· Represent the revenue cycle team in cross-departmental meetings and initiatives.

· Adherence to the company’s telecommuter policy.