Prior Authorization Specialist

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Prior Authorization Specialist

San Diego, CA, United States

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Job Title: Prior Authorization Specialist

Department: Revenue Cycle / Billing

Reports To: Sr. Director of Billing and Reimbursement

Location: Onsite Preferred - Work From Home

Position Summary

The Prior Authorization Specialist is responsible for the timely and accurate submission of prior authorizations for Category I molecular pathology testing. The role requires reviewing clinical documentation, applying payer-specific medical necessity criteria, and ensuring alignment between CPT and ICD-10 coding. This position supports revenue cycle performance by minimizing authorization-related denials and delays.

Core Responsibilities

• Submit and manage high-volume prior authorizations (~75-100 per day)
• Review and interpret medical records, clinical documentation, and lab requisitions
• Responsible for reviewing and submitting authorization level appeals
• Data entry, correct insurance assignment to patient accounts, insurance eligibility verification
• Review/update demographics and patient information for accuracy
• Ensure appropriate linkage between CPT codes and ICD-10 diagnoses
• Apply payer policies across Commercial, Medicare Advantage, and Medicaid payers
• Utilize payer portals, automated tools, and internal systems to process authorizations
• Monitor and track authorization statuses and complete required follow-up actions
• Collaborate with internal billing teams to resolve authorization discrepancies
• Maintain full compliance with HIPAA regulations and payer guidelines

Minimum Qualifications

• 2-4 years of relevant experience in:

• Prior authorization processing

• Laboratory billing

• Healthcare revenue cycle

• High school diploma required; some college preferred

• Working knowledge of:

• CPT coding (molecular preferred)

• ICD-10 coding and medical necessity guidelines

• Ability to interpret clinical documentation and testing requests

• Strong knowledge and experience with Microsoft Excel as well as Word and Outlook, general office equipment, and ten-key by touch

• Ability to easily adapt to increased business demands

Skills & Competencies

• Strong analytical and critical thinking skills
• High level of attention to detail and accuracy
• Ability to interpret and apply payer policies
• Effective internal communication skills
• Ability to work in a high-volume, production-driven environment
• Strong organizational and multi-tasking capabilities
• Self-starter, ability to work independently.
• Excellent communication and customer service skills; cooperative, work collaboratively and treat others in respectful, professional and supportive manner.
• Desire to learn and apply learned concepts to various situations.

Tools & Systems

• Salesforce
• Glidian
• XIFIN
• Payer portals and automated authorization platforms
• Microsoft Excel

Performance Expectations

• Meet or exceed daily productivity targets (authorization volume)
• Maintain high accuracy and data integrity
• Ensure timely submission and follow-up
• Adhere to payer requirements and compliance standards

Ready to make a difference in women's health? Apply today and join our team of passionate innovators at Hologic!

The annualized base salary range for this role is $48,800 to $73,300 and is bonus eligible. Final compensation packages will ultimately depend on factors including relevant experience, skillset, knowledge, geography, education, business needs and market demand.

Agency And Third Party Recruiter Notice: Agencies that submit a resume to Hologic must have a current executed Hologic Agency Agreement executed by a member of the Human Resource Department. In addition, Agencies may only submit candidates to positions for which they have been invited to do so by a Hologic Recruiter. All resumes must be sent to the Hologic Recruiter under these terms or they will not be considered.

Hologic, Inc. is proud to be an Equal Opportunity Employer inclusive of disability and veterans.

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