Pre Authorization Analyst - Infusion Clinic

About the Role

The Pre Authorization Analyst plays a critical role in the healthcare insurance process by ensuring that medical services, medications, outpatient infusions and procedures are appropriately authorized before they are performed. This position involves thorough review and analysis of medical documentation, insurance policies, and regulatory guidelines to determine coverage eligibility and compliance. The analyst collaborates closely with healthcare providers, insurance representatives, and patients to facilitate timely approvals and resolve any discrepancies or issues.

By accurately assessing authorization requests, the analyst helps to minimize claim denials and delays, thereby improving patient care and operational efficiency. Ultimately, this role supports the financial integrity of the organization while ensuring adherence to healthcare regulations and policies.

• High school diploma or equivalent.
• Minimum of 1-2 years' experience in healthcare insurance, medical billing, or pre-authorization processing.
• Strong understanding of medical terminology, insurance policies, and healthcare regulations.
• Proficiency with electronic health records (EHR) systems and authorization management software.
• Excellent communication and organizational skills.

• Certification in medical billing, coding, or healthcare administration (e.g., CPC, CPMA).
• Experience working with multiple insurance providers and familiarity with Medicare and Medicaid authorization processes.
• Advanced knowledge of healthcare compliance standards such as HIPAA.
• Demonstrated ability to analyze complex medical information and make sound authorization decisions.
• Experience in a fast-paced healthcare or insurance environment.

• Review and evaluate pre-authorization requests for medical procedures, outpatient infusion treatments, and services to ensure compliance with insurance policies and clinical guidelines.
• Analyze patient medical records, physician notes, and diagnostic reports to verify the necessity and appropriateness of requested services.
• Communicate effectively with healthcare providers, insurance companies, and patients to obtain additional information or clarify authorization requirements.
• Document authorization decisions accurately in the system and maintain detailed records for audit and reporting purposes.
• Identify and escalate complex cases or potential fraud to appropriate departments for further investigation.
• Stay current with changes in healthcare regulations, insurance policies, and industry best practices to ensure compliance.
• Collaborate with internal teams to streamline authorization processes and improve turnaround times.

The Pre Authorization Analyst utilizes strong analytical skills daily to review and interpret medical documentation and insurance policies, ensuring that authorization decisions are accurate and compliant. Effective communication skills are essential for interacting with healthcare providers, insurance representatives, and patients to gather necessary information and explain authorization outcomes. Organizational skills are applied to manage multiple cases simultaneously, maintain detailed records, and meet strict turnaround times.

Familiarity with healthcare software systems enables efficient processing and documentation of authorization requests. Additionally, problem-solving skills help the analyst identify discrepancies or potential issues and collaborate with teams to resolve them promptly.

Monday - Fridays 8-4:30pm