Prior Authorization Specialist

Pride Health is hiring a Prior Authorization Specialist to support our client's healthcare facility in Sumter, SC. Interested? Apply Today!

Job Details:

Schedule: Business Hours EST

Location: Sumter, SC 29150 or Remote

Job Type: Contract

Contract Length: 27 Week/s

Pay Rate: $13/hour

• Pay offered is based on experience, expertise, credentialing, and education.

Position Summary:

Responsible for obtaining prior authorizations and pre-certifications for ancillary testing, procedures, medications, and specialty treatments to ensure timely patient care and compliance with insurance requirements. This role serves as a liaison between providers, patients, insurance companies, and ancillary service departments to facilitate approval of medically necessary services.

Duties:

• Obtain prior authorizations and pre-certifications for ancillary diagnostic testing and procedures.
• Verify patient insurance benefits and authorization requirements.
• Submit clinical documentation and supporting medical records to insurance carriers as required.
• Monitor authorization status and follow up with payers to ensure timely approvals.
• Communicate authorization approvals, denials, and pending requests to providers, clinical staff, and patients.
• Review denial determinations and coordinate appeals when appropriate.
• Maintain accurate documentation of authorization requests and outcomes within the electronic medical record (EMR) system.
• Ensure compliance with payer guidelines, regulatory requirements, and organizational policies.
• Collaborate with physicians, nurses, and ancillary departments to obtain necessary clinical information for authorization submissions.
• Assist with tracking authorization expiration dates and obtaining extensions when necessary.
• Provide exceptional customer service while maintaining patient confidentiality.

Requirements:

• High school diploma or equivalent required; associate degree preferred.
• Previous experience in medical insurance verification, prior authorization, or healthcare administration preferred.
• Knowledge of medical terminology, diagnostic testing, and specialty medication authorization processes.
• Familiarity with EMR systems and insurance payer portals.
• Strong organizational, communication, and multitasking skills.
• Ability to work independently and manage multiple priorities in a fast-paced healthcare environment.
• Understanding of HIPAA regulations and patient confidentiality requirements.

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For workers in the United States, PrideGlobal and it's affiliates offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, pet insurance and employee discounts with preferred vendors.

Equal Employment Opportunity

PrideGlobal and it's affiliates are an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

PrideGlobal and it's affiliates are a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.

Only applicable for San Francisco Candidates: Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, any inquiry of parental leave or lactation accommodation.

Only applicable for Kentucky positions: For this type of employment, state law requires a criminal record check as a condition of employment. This applies to direct care staff (Examples: RN, LPN, Nurse Aides, Therapists) referred to Kentucky nursing facilities, assisted living communities, or long-term care facilities, in accordance with KRS 216.793.