Specialist, Prior Authorization

Who We Are:

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Clark Regional Medical Center is a 79 bed community hospital featuring updated technology including new and expanded services such as Diagnostic Services, larger capacity Emergency Services, home-like Labor and Delivery Suites, and a skilled nursing facility. The campus also includes a 45,000 square foot Medical Plaza housing the Clark Clinic, Diagnostic Center for Women, Center for Rehabilitation, Specialty Clinic and Anticoagulation Clinic.

Where We Are:

Winchester offers a truly original experience to all with so much to do and see. Just a short drive from Lexington, the "Horse Capital of the World," and the Red River Gorge, you can experience all the beauty and excitement nature has to offer. 

Why Join Us

We believe that investing in our employees is the first step to providing excellent patient care.

Benefits Include:

• Comprehensive Health Coverage: Medical, dental, and vision plans (starting at low cost options)
• Financial Protection: Life, accident, disability, and critical illness coverage
• Paid Time Off & Leave: Generous PTO and paid family leave
• Retirement Planning: 401(k) with company match
• Tuition Assistance: Education support for career advancement
• Wellness Programs: Free gym memberships, mental health services, and virtual care
• Employee Assistance Program: Support for mental, physical, and financial well-being
• Additional Perks: Discount programs, free parking, and more

Job Summary

The Prior Authorization Specialist works collaboratively with clinical departments and insurance providers to obtain required pre-certifications and authorizations for scheduled services. This role ensures all authorizations are accurately documented in the system to support proper billing and reimbursement.

The specialist maintains a strong understanding of payer requirements, insurance policies, and authorization processes to ensure compliance and efficiency.

Key Responsibilities

• Contact insurance carriers to verify benefits, policy limitations, and obtain authorizations/pre-certifications
• Follow up with physician offices, financial counselors, patients, and third-party payers to complete authorization processes
• Ensure all information is accurate and complete, applying knowledge of Medicare, Medicaid, and commercial payer requirements
• Educate patients, staff, and providers on authorization requirements, eligibility guidelines, and payer policies
• Monitor and confirm that all scheduled services have appropriate prior authorizations
• Coordinate peer-to-peer reviews when required by insurance companies
• Notify appropriate parties of authorization denials, coverage lapses, or self-pay status
• Assist with scheduling diagnostic tests, procedures, and specialty appointments as needed
• Maintain accurate referral and insurance records in the system
• Stay up to date on payer guidelines, insurance plans, and authorization requirements

Minimum Qualifications

• High School Diploma or equivalent (Required)
• One (1) year of experience in healthcare, insurance verification, or prior authorization (Preferred)

Required Skills & Competencies

• Knowledge of Medicare, Medicaid, and third-party payer requirements
• Strong attention to detail and accuracy
• Excellent communication and customer service skills
• Ability to manage multiple tasks and meet deadlines
• Proficiency with electronic medical records and eligibility systems
• Problem-solving and critical thinking skills

EEOC Statement:

Clark Regional Medical Center is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.