Clinical Support Specialist - 2680

• 2+ years prior authorization experience required.

Job Summary

The Clinical Support Specialist is responsible for completing prior authorizations and supporting all aspects of the PA process, including documentation, expedited reviews, appeals, and cross-functional coordination. This role is accountable for meeting established KPIs (e.g., turnaround time, completion rate, approval ratio), participating in process improvement initiatives, and supporting retraining efforts during workflow transitions. The Specialist utilizes automation platforms and reporting tools to streamline operations and improve provider/patient experience.

Duties and Responsibilities

• Complete prior authorization requests promptly and accurately, ensuring compliance with established KPIs (turnaround time, completion rate, approval ratio, documentation accuracy, error rate, staff productivity, automation utilization).
• Accurately enter and track PA data in designated systems to support KPI monitoring and reporting.
• Document all account activity and respond to inquiries in a timely manner.
• Identify, analyze, and escalate trends or issues resulting in denials and delays; participate in root cause analysis and implement new procedures to improve effectiveness.
• Collaborate with pharmacy operations, clinical teams, and external partners to resolve PA issues and share best practices.
• Support retraining efforts for clinic and pharmacy staff during workflow transitions.
• Maintain extensive working knowledge of insurance companies, billing authorization requirements, and payer processes.
• Communicate with members, prescribers, pharmacy teams, insurance companies, and referring physicians to resolve coverage issues and expedite approvals.
• Utilize automation platforms (e.g., CoverMyMeds) and provider portals to streamline PA processing and improve efficiency.
• Demonstrate strong people skills, build effective working relationships, and contribute to a positive team environment.
• Exhibit strong time management and organizational skills to prioritize and meet deadlines.
• critical thinking and independent decision-making to support the authorization process.
• Uphold HIPAA standards and maintain the security and privacy of all information owned by AbsoluteCare or maintained on behalf of members, employees, and business partners.
• Management may assign or reassign duties at any time; the job description is subject to change.

Minimum Qualifications

• High School Diploma
• Pharmacy Technician or Medical Assistant.
• 2+ years prior authorization experience required.

• Experience using Electronic Medical Records preferred
• Experience with CoverMyMeds and other automation platforms preferred.
• Knowledge of payer processes and appropriate clinical documentation submission.
• Excellent interpersonal and communication skills.
• Creative, innovative, and able to independently solve problems.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Working knowledge of Microsoft Office Suite (Word, Outlook, PowerPoint, and Excel).
• Experience in a high-volume, multi-site environment preferred.

Working Conditions

Remote role with flexibility to work from home; may be required to report to clinic or designated on-site location as operational needs arise. You will need a dedicated, quiet workspace that is conducive to conducting telephonic outreach while adhering to HIPAA and other privacy policies. All necessary electronic supplies, including a laptop, monitors, and any other hardware or software required to perform your duties effectively, will be provided. You will be responsible for setting up and maintaining these tools in your home workspace. A reliable and high-speed Wi-Fi connection or home internet is required to perform the essential functions of this role.

Physical Requirements

• Ability to remain stationary for extended periods of time.
• Repetitious movements.

• Frequently move equipment or supplies weighing up to 20 lbs.

Direct Reports

None

All Employees are expected to maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.

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