Preauthorization Specialist - JRMC Pain Clinic

Description

 Job Title: Preauthorization Specialist for JRMC Pain Clinic

Reports to: Chief Financial Officer 

Department: Outpatient Pain Clinic

Job Summary: The Preauthorization Specialist is a full-time, non-exempt position.  This ideal candidate will be responsible for coordinating and securing prior authorizations for all outpatient pain management procedures and outpatient infusion services, ensuring accurate scheduling, optimizing patient flow, and supporting revenue-cycle compliance. This role works closely with providers, nursing staff, billing/coding, case management, and insurance companies to verify benefits, obtain required approvals, and communicate updates to patients and clinical teams. 

This position plays a critical role in preventing treatment delays, reducing denials, and ensuring proper patient preparation and documentation for each date of service.

Demonstrates Competency in the following areas:

Reviews provider orders and clinical documentation for competencies prior to submission.

Obtains preauthorization for all pain procedures, injections, blocks, ablations, and other interventions. 

Will work closely with the Pharmacy Director to ensure availability and secure preauthorization for infusion therapies, including but not limited to biologics, antibiotics, hydration, chemotherapy supportive medications, iron, and specialty infusions. 

Verifies patient insurance benefits, coverage limitations, and out-of-pocket requirements.

Communicate with payors to resolve discrepancies, request extensions, and appeal initial denials.

Tracks authorization status and maintains documentation consistent with hospital, CMS, and payor guidelines.

Ensure authorizations are linked correctly to scheduled visits in the EMR/practice management system.

Notifies providers promptly of missing documentation or payor-required criteria.

Coordinates and schedules all outpatient pain procedures and infusion appointments.

Ensures proper spacing, room availability, and staffing alignment for safe patient flow.

Confirms transport needs, special equipment, delivery schedules, and pharmacy preparation times.

Provides appointment reminders and communicates prep instructions to patients.

Schedules follow-up appointments as required by clinical protocols and payor standards.

Serves as the primary point of contact for patients regarding insurance status, authorization requirements, and appointment details.

Provides clear, compassionate education about prep instructions, arrival times, and expectations.

Assists with financial counseling referrals when patients require cost estimates or payment arrangements.

Ensures correct CPT/HCPCS codes, ICD-10 diagnoses, and documentation align with preauthorization requirements.

Works collaboratively with coding, billing, and pharmacy to prevent claim denials.

Participates in denial management and supplies payor-required documentation for appeals.

Maintain compliance with HIPAA, CMS guidelines, ADH requirements, and payer-specific rules.

Logs all authorizations in the EMR according to internal policy and audit readiness standards.

Communicates daily with pain clinic and infusion center staff regarding authorization status, cancellations, and scheduling changes.

Alerts nursing staff immediately when authorizations are pending but a patient is arriving soon.

Assists with rescheduling when infusions require biologic delivery windows or timing changes.

Participates in daily huddles, throughput meetings, and quality improvement activities.

Requirements

Regulatory Requirements:

High School graduate or equivalent. 

Associate degree in healthcare administration, billing, or related field preferred.

Minimum 1-2 years of experience in scheduling, insurance verification, preauthorization, medical billing.

Experience in outpatient pain management, infusion therapy, or specialty pharmacy preferred.

Familiarity with CMS guidelines, Medicaid, Medicare, Medicare Advantage and Commercial insurance payers and processes.

Core Competencies:

Accuracy and attention to detail.

Excellent communication and teamwork.

Problem-solving and denial prevention.

Patient-centered service.

Reliability and accountability.

Workflow efficiency and time management.

Language Skills:

Able to communicate effectively in English, both verbally and in writing.

Additional languages are preferred.

Physical Demands:

Interactions with patients, staff, and insurance representatives daily.

Normal office and outpatient clinical environmen