Virtual Prior Authorization Specialist

Job Description: Virtual Prior Authorization Specialist

Company Overview: Rume Health is a leading healthcare organization dedicated to providing quality care and innovative solutions to improve patient outcomes. We are seeking a Virtual Prior Authorization Specialist to join our dynamic team and support our mission of delivering exceptional patient care.

Position Overview: As a Virtual Prior Authorization Specialist at Rume Health, you will play a vital role in obtaining prior authorizations for medical treatments, procedures, and medications. You will work remotely under the guidance of our Clinical Operations Director, collaborating with healthcare providers, insurance companies, and patients to ensure timely approvals and seamless coordination of care.

Key Responsibilities:

Prior Authorization Processing:

Initiate and complete prior authorization requests for medical services, treatments, and prescription medications.

Review clinical documentation, verify insurance coverage, and gather necessary information for submission.

Insurance Verification:

Verify patient insurance information, including eligibility, benefits, and coverage limitations related to prior authorizations.

Communicate with insurance companies or pharmacy benefit managers (PBMs) to obtain authorization approvals.

Documentation and Record Keeping:

Maintain accurate records of prior authorization requests, approvals, denials, and appeals.

Ensure compliance with regulatory requirements and organizational policies regarding documentation and data privacy.

Collaboration and Communication:

Collaborate with healthcare providers, pharmacists, and case managers to facilitate the prior authorization process.

Communicate with patients regarding authorization status, requirements, and next steps in the care plan.

Quality Assurance:

Perform quality checks on prior authorization submissions to ensure completeness, accuracy, and adherence to clinical guidelines.

Identify opportunities for process improvement and efficiency in prior authorization management.

Qualifications:

Available to work the hours of 8:00 AM – 4:30 PM PST

Bachelor’s degree in healthcare administration, nursing, or related field preferred.

Proven experience as a prior authorization specialist or similar role in healthcare.

Knowledge of medical terminology, insurance policies, and prior authorization processes.

Strong communication skills, both written and verbal, with the ability to interact professionally with stakeholders.

Proficiency in using electronic health records (EHR), insurance verification systems, and Microsoft Office Suite.

Detail-oriented with excellent organizational and time management skills.

Ability to work independently in a virtual environment and prioritize tasks effectively.