Prior Authorization Specialist

About the role

We are seeking an experienced specialist to refine our authorization automation platform tailored for the home health and hospice sectors. You will bridge the gap between complex payer requirements and software logic to eliminate administrative bottlenecks. In this capacity, you will own the evaluation and optimization of automated authorization requests to ensure they meet strict standards of quality, accuracy, and speed. You will collaborate directly with engineering and product teams to translate nuanced payer rules into functional and reliable software workflows. The role requires you to develop and continuously update standard operating procedures for a diverse range of insurance types, including Medicare Advantage, Medicaid, and commercial plans. You will work closely with client intake and billing departments to troubleshoot specific issues and align platform settings with their operational realities. A core part of the position involves tracking key performance indicators such as denial trends, approval rates, and response times to drive iterative system improvements. You will be instrumental in ensuring that the automation logic reflects the evolving landscape of post-acute care authorization.

Key facts

What you'll do

• Evaluate automated authorization requests to ensure they meet quality, accuracy, and speed standards.
• Collaborate with engineering and product staff to convert payer rules into functional software workflows.
• Develop and update standard operating procedures for various insurance types, including Medicare Advantage, Medicaid, and commercial plans.
• Consult with client intake and billing departments to troubleshoot issues and align platform settings with their specific operational needs.
• Track key performance indicators such as denial trends, approval rates, and response times to drive system improvements.
• Analyze complex payer policies and coverage criteria to refine automated decision-making logic.
• Serve as a primary point of contact for cross-functional teams regarding authorization process enhancements.
• Conduct detailed testing of new workflows to validate functionality before full deployment.
• Interpret payer feedback and adjust system configurations to reduce manual intervention.
• Maintain a comprehensive understanding of payer portal requirements to secure timely authorizations.
• Monitor system performance metrics to identify bottlenecks and implement corrective actions.
• Facilitate training sessions for operational staff on updated procedures and platform features.
• Ensure all documentation reflects current payer guidelines and internal best practices.
• Support the continuous refinement of the platform to improve authorization success rates.

Requirements

• Minimum of 3 years of hands-on experience in prior authorization within post-acute care, home health, or hospice.
• Extensive knowledge of authorization workflows for commercial, Medicaid, managed Medicaid, and Medicare Advantage plans.
• Proven ability to navigate various payer portals to secure authorizations.
• Proficiency in managing referral workflows, eligibility checks, and documentation requirements.
• Ability to document clear processes and SOPs.
• High level of organizational skill and attention to detail.
• Ability to function effectively in an early-stage startup environment.
• Must be legally authorized to work in the United States without sponsorship for the position of Prior Authorization Specialist at Claim Health.
• Current authorization to work in New York City is required if the role location is listed as New York City.
• You must submit a resume that clearly demonstrates the required experience and skills as stated in the job description.
• Applications missing the required information or that do not clearly meet the stated requirements will not be reviewed.
• You must be available to work on-site in New York City for the duration of the role.
• You must possess the right to work in the United States and currently reside in New York City.

Nice to have

• Clinical credentials such as RN or LPN.
• Familiarity with HomeCare HomeBase (HCHB), Axxess, WellSky, or KanTime.
• Experience with referral management platforms like Forcura, Careport, or Ensocare.
• Background working with revenue cycle management software or automation vendors.
• Specific expertise in hospice authorization requirements and Medicaid room and board procedures.

Practical notes

This role requires consistent presence on-site in New York City during standard business hours. The position does not offer remote or hybrid arrangements. Candidates must be prepared for ongoing in-person collaboration with engineering, product, and operations teams. Travel is not required for this position. The role is contingent upon successful completion of standard employment verification and work authorization documentation. Only candidates who meet the location and work authorization requirements will be considered for employment. The compensation details are not specified in the source material provided for this position. This role is embedded within the Operations team and reports to the relevant operational leadership. Success in this position depends on the ability to thrive in a dynamic, early-stage environment where processes are actively evolving. The work performed will directly impact the efficiency of revenue cycle operations for post-acute care providers.