Authorization Specialist – Tawam Fertility Center

About the role

The Specialist‑Authorization is responsible for initiating pre‑authorization requests to payers for claims that require approval. The role involves extensive communication with payers, patients, physician offices, and hospital clinical staff, and focuses on pre‑certifying procedures ordered by physicians while monitoring medical necessity.

Key responsibilities

• Initiate pre‑authorization requests to payers for claims requiring approval.
• Communicate with payers, patients, physician offices, and hospital clinical staff.
• Pre‑certify procedures ordered by physicians and monitor appropriateness and medical necessity.
• Collect clinical information, update systems with accurate authorization data, and verify eligibility.
• Notify service‑line partners when rescheduling is needed due to lack of authorization or limited benefits.
• Manage inpatient admission notifications to protect the organization’s financial standing.
• Document benefits, authorizations, and financial obligations clearly on account memos.
• Coordinate with physicians, case management, and utilization review to provide supporting clinical information.
• Monitor mailbox, email, faxes and phone calls to resolve pre‑access issues within defined time frames.
• Research and stay informed on insurance criteria for prior authorizations.

Required profile

• 12 years of revenue‑cycle experience (in lieu of a degree).
• Healthcare certification such as CRCR and/or CHAM.
• Minimum 1–3 years of prior‑authorization experience in a large, integrated healthcare network.
• Experience with medical insurance verification, billing and coding (CPT, ICD‑10, HCPCS).
• Knowledge of third‑party payer requirements, contracts, and payment practices.

Required skills

• Microsoft Office and Outlook.
• Medical terminology and coding.
• CPT, ICD‑10 and HCPCS coding systems.
• Healthcare revenue‑cycle systems.
• CRCR and CHAM certification knowledge.
• Insurance terminology and payer process familiarity.