Facility Prior Authorization Specialist Urology | Permanent WFH

We are seeking an experienced Facility Prior Authorization Specialist to support a busy urology practice by managing the authorization process for facility-based procedures, surgeries, and services. This role is responsible for verifying insurance requirements, submitting authorization requests, gathering supporting clinical documentation, monitoring payer responses, and ensuring approvals are secured before scheduled procedures.

The ideal candidate has hands-on experience with facility or surgical prior authorizations, strong knowledge of insurance requirements and payer workflows, and proficiency in ModMed. Urology experience is highly preferred, particularly with outpatient hospital and ambulatory surgery procedures.

Key Responsibilities

• Manage the end-to-end facility prior authorization process for urology procedures, surgeries, and facility-based services.
• Verify patient insurance eligibility, benefits, and authorization requirements.
• Review scheduled procedures to determine authorization requirements based on the payer, procedure, diagnosis, and place of service.
• Submit authorization requests through payer portals, fax, phone, and other payer-specific channels.
• Gather and submit required clinical documentation, including office notes, imaging, laboratory results, treatment history, and other supporting records.
• Coordinate with providers, nurses, clinical staff, surgery schedulers, and facility representatives to obtain missing information or documentation.
• Monitor pending authorization requests and proactively follow up with insurance carriers to secure timely determinations.
• Document authorization details in ModMed, including authorization numbers, reference numbers, approval dates, expiration dates, and payer communications.
• Communicate authorization status, pending requirements, approvals, and denials to relevant internal teams.
• Identify potential authorization issues or delays and escalate concerns promptly to help prevent procedure cancellations or rescheduling.
• Manage authorization denials, requests for additional clinical information, and peer-to-peer review requirements when applicable.
• Maintain accurate and timely records across the EMR and payer systems.
• Ensure authorization requests are submitted within payer-specific deadlines and follow applicable insurance guidelines.
• Maintain patient confidentiality and comply with HIPAA and organizational policies.
  
  

Qualifications

• Previous experience in medical prior authorization, preferably involving facility-based procedures, surgeries, or outpatient services.
• ModMed experience required.
• Experience working with commercial insurance plans, Medicare, Medicaid, and/or other third-party payers.
• Strong understanding of insurance benefits, prior authorization requirements, CPT and ICD-10 codes, and medical terminology.
• Experience using payer portals and submitting clinical documentation.
• Strong organizational and follow-up skills with the ability to manage multiple authorization requests and deadlines.
• Excellent written and verbal communication skills.
• Strong attention to detail and accuracy.
• Ability to work independently while coordinating effectively with providers, clinical teams, schedulers, and insurance representatives.
• Urology experience strongly preferred.
• Experience with outpatient hospital procedures, ambulatory surgery centers (ASCs), and other facility-based services.
• Familiarity with urology procedures such as cystoscopy, TURP, UroLift, Rezm, lithotripsy, biopsies, and other surgical or interventional procedures.
• Experience handling authorization denials, clinical reviews, peer-to-peer requests, and additional documentation requirements.
• Knowledge of major payer authorization processes and requirements.
  
  

Perks

• Permanent Work From Home
• Leave Credits
• Monetary Allowance
• Annual Bonus
• Weekly Paychecks
• Fixed Weekends Off
• Thriving Company Culture with Complete Autonomy
• Exclusive Specialized Training Programs
• Unlock Your Potential with a Highly Competitive Salary
  
  

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