Prior Authorization - Surgery | Permanent WFH

We are seeking a highly organized and experienced Prior Authorization Specialist – Surgery to support a U.S.-based healthcare organization in managing surgical authorization requests for inpatient and outpatient procedures.

The ideal candidate has extensive experience in surgical prior authorizations, proficiency in Epic EMR, and a strong understanding of payer requirements, medical necessity guidelines, and expedited authorization processes.

This role requires the ability to independently manage 20+ authorization requests daily, coordinate with insurance providers and surgical teams, and ensure timely approvals to prevent procedure delays and authorization-related claim denials.

Key Responsibilities

• Manage and process 20+ prior authorization requests daily for inpatient and outpatient surgical procedures, ensuring accuracy and timely completion.
• Review surgical orders, CPT/HCPCS codes, ICD-10 codes, and supporting clinical documentation in Epic to determine authorization requirements.
• Submit, monitor, and follow up on authorization requests through payer portals, including Availity, UnitedHealthcare, Aetna, Cigna, Humana, BCBS, eviCore, and Carelon.
• Identify urgent and time-sensitive surgical cases and initiate expedited authorization requests with appropriate clinical justification.
• Monitor pending authorizations and proactively escalate delayed requests to prevent surgical cancellations or rescheduling.
• Coordinate peer-to-peer reviews between surgeons and insurance medical directors for pending or denied authorization requests.
• Process authorization modifications, including changes in procedure codes, surgery dates, service locations, and authorization extensions.
• Verify patient insurance eligibility, benefits, and coverage requirements before scheduled procedures.
• Maintain accurate documentation of authorization statuses, payer communications, reference numbers, and determinations within Epic.
• Collaborate with surgeons, surgical schedulers, clinical staff, and insurance representatives to resolve authorization-related concerns.
• Stay updated on payer policies, medical necessity criteria, and authorization guidelines to ensure compliance and operational efficiency.
• Ensure all patient information is handled in accordance with HIPAA regulations and organizational policies.
  
  

Qualifications

• At least 3 years of experience in prior authorization, including a minimum of 2 years specifically handling surgical procedures.
• Hands-on experience using Epic EMR, particularly authorization/referral workflows, work queues, and scheduling modules such as Cadence or OpTime.
• Proven ability to process 20+ surgical prior authorizations daily while maintaining accuracy and meeting turnaround expectations.
• Strong experience navigating insurance payer portals, including Availity, UHC, Aetna, Cigna, Humana, BCBS, eviCore, and Carelon.
• Solid understanding of inpatient and outpatient surgical authorization requirements and medical necessity guidelines.
• Knowledge of CPT, HCPCS, and ICD-10 coding systems.
• Familiarity with commercial insurance, Medicare Advantage, and Medicaid authorization policies.
• Demonstrated experience managing urgent and expedited authorization requests.
• Working knowledge of clinical review criteria, including InterQual, MCG, and payer-specific medical necessity policies.
• Strong attention to detail and commitment to maintaining HIPAA compliance.
• Prior authorization experience in surgical specialties such as Orthopedics, Spine, Neurosurgery, General Surgery, or ENT.
• Experience supporting ambulatory surgery centers (ASCs), hospitals, or surgical departments.
• Background in coordinating peer-to-peer reviews, managing authorization denials, and supporting appeals.
• Relevant certifications such as CPAR, CRCS, or CPC.
• Previous experience working remotely within a U.S. healthcare organization or revenue cycle management (RCM) team.
• Amenable to work during US hours
• Must be willing to undergo a background check as part of the hiring process.
  
  

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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Who are we

BizForce is one of the fastest-growing global outsourcing companies in the world, founded in the US in Tucson, Arizona and is now operational in PH!

Our Commitment to delivering high-quality results for our clients and the only way to do that is ensuring a rewarding, respectful and productive experience for our employees. We hold the same values for both our customers and our employees.