Job Overview:
Our client is seeking a Prior Authorization Specialist (Behavioral/Mental Health) to manage insurance authorizations, medication access, pharmacy coordination, and payer communications. In this role, you will ensure that patient medications and treatment authorizations are secured and properly coordinated to support timely and uninterrupted care. You will communicate directly with insurance companies, pharmacies, physicians, and internal clinical teams to maintain continuous care delivery. The ideal candidate is persistent, organized, detail-oriented, and comfortable advocating for patients through complex insurance processes.
Schedule: Monday to Friday, 9:00 AM to 6:00 PM CDT (Texas), with a 1-hour unpaid break; Full-time, 40 work hours per week
Responsibilities
Prior Authorization & Insurance Coordination:
- Contact insurance companies daily to check the status of prior authorization requests, obtain reference numbers, and follow up on delayed or stalled requests.
- Manage insurance denials from start to finish, including identifying denial reasons and determining appropriate next steps.
- Coordinate peer-to-peer reviews between insurance companies and prescribing physicians.
- Prepare and draft appeals, letters of medical necessity, and other supporting documentation required for authorization.
- Monitor payer policy changes, coverage requirements, and updated criteria for Spravato and related medications.
- Communicate insurance and coverage updates to clinical, billing, and scheduling teams.
- Serve as the primary point of contact for payer case managers and utilization review teams.
Pharmacy & Medication Delivery Coordination:
- Coordinate with specialty pharmacies and medication distributors to schedule patient-specific medication shipments and confirm delivery dates.
- Verify that the correct medication has been received and is properly logged before each scheduled treatment session.
- Reconcile medication shipments against the scheduling system and promptly identify discrepancies, delays, missing items, or short shipments.
- Support REMS requirements and documentation for Spravato, coordinating with the certified treatment center and pharmacy as needed.
- Assist with medication inventory tracking and controlled-substance logging in coordination with clinical staff.
Documentation & Workflow Management:
- Maintain an accurate and up-to-date prior authorization and medication tracking log.
- Document all payer, pharmacy, and relevant patient-related communications accurately in the EHR.
- Coordinate closely with scheduling, billing, pharmacy, and clinical teams to ensure treatment dates, insurance authorizations, and medication availability remain aligned.
- Track pending cases and proactively follow up to prevent authorization or medication delays.
- Identify recurring authorization, payer, or pharmacy bottlenecks and recommend workflow improvements.
- Maintain strict HIPAA compliance when handling patient, payer, pharmacy, and clinical information.
Requirements:
- Prior experience in prior authorization, medical billing, insurance verification, utilization management, or specialty pharmacy.
- Familiarity with commercial insurance plans and Medicare.
- Experience within a behavioral or mental health clinic/facility.
- Strong telephone communication skills and a professional phone presence.
- Comfortable spending extended periods on hold with insurance companies and conducting persistent follow-up.
- Excellent attention to detail and strong organizational and documentation skills.
- Ability to manage a high volume of concurrent authorization and medication-access cases while maintaining accuracy.
- Strong follow-through and ability to prioritize time-sensitive requests.
- Proficiency with EHR systems, insurance portals, and standard office software.
- Strong understanding of patient confidentiality and HIPAA requirements.
Preferred Qualifications:
- Experience working directly with insurance companies and payer portals.
- Spravato (esketamine) authorization and coordination experience.
- Knowledge of REMS program requirements.
- Specialty pharmacy coordination experience.
- Prior authorization appeals and peer-to-peer review coordination experience.
- Experience drafting letters of medical necessity.
- Utilization review experience.
- Behavioral health or psychiatric treatment workflows experience.
- Controlled medication inventory and documentation experience.
Independent Contractor Perks:
- Permanent work from home
- Immediate hiring
- Health Insurance Coverage for eligible locations
Note:
Please click the "Apply" button to complete your application, including the assessment questions, technical check, and voice recording. Your hourly pay rate will be established based on your performance in the application process; submissions with all requirements fulfilled will receive priority review.
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