Job Description

Job Description

Medical Preauthorization & Medical Review Specialist

Job Summary

The Medical Preauthorization & Medical Review Specialist supports timely, accurate coverage decisions by obtaining prior authorizations and conducting medical necessity reviews for requested services. This role reviews clinical documentation against payer policies and evidence-based guidelines, coordinates with providers and internal teams, and ensures all determinations and communications are completed within required turnaround times while maintaining compliance and high service standards.

Key Responsibilities

• Process prior authorizations for outpatient, inpatient, and ancillary services (e.g., imaging, procedures, DME, therapies, specialty drugs), as applicable.
• Perform initial and/or ongoing medical necessity reviews using payer medical policies and clinical criteria (e.g., InterQual/MCG or plan-specific guidelines, if applicable).
• Collect, validate, and organize clinical documentation (H&P, progress notes, labs, imaging reports, operative notes, treatment plans).
• Identify missing or conflicting information and proactively request additional documentation from provider offices or facilities.
• Collaborate with physicians/clinical reviewers and escalate cases that require peer-to-peer review or medical director determination.
• Submit authorizations via payer portals, phone, fax, and electronic systems; track status and follow up to prevent delays.
• Document all actions, decisions, and communications thoroughly in applicable systems (UM platform, EHR, CRM, etc.).
• Communicate determinations and next steps to providers and internal stakeholders in a clear, professional manner.
• Support appeals and reconsiderations by compiling records, timelines, and rationale aligned with policy and criteria.
• Monitor queues and prioritize work based on urgency, service dates, and regulatory/payer turnaround requirements.
• Maintain knowledge of payer rules, CPT/HCPCS/ICD-10 basics, and medical terminology relevant to assigned service lines.
• Participate in audits, quality reviews, and process improvements to increase approval rates and reduce denials.

Required Qualifications

• High school diploma or equivalent required; associate or bachelor’s degree preferred.
• 2+ years of experience in prior authorizations, utilization management, medical review, revenue cycle, or provider office/payer operations.
• Strong understanding of medical terminology and clinical documentation.
• Working knowledge of health insurance benefit structures and payer authorization processes.
• Strong attention to detail, documentation quality, and ability to manage multiple cases with deadlines.
• Proficiency with payer portals and standard office software (Excel, Outlook) and ability to learn new systems quickly.

Preferred Qualifications (as applicable)

• Clinical licensure: RN/LPN/LVN or other clinical license (if role includes clinical decision support).
• Certifications: CPC, CCS, CRC, or UM-related certification (e.g., CPUR).
• Experience with Medicare Advantage, Medicaid, and/or commercial plans.
• Familiarity with HIPAA, NCQA/URAC standards, and medical necessity/level-of-care reviews.

Skills & Competencies

• Clear written and verbal communication with provider offices and internal clinical teams.
• Professional judgment, discretion, and ability to handle sensitive health information.
• Strong time management and prioritization in a high-volume environment.
• Problem-solving mindset with persistence in follow-up and resolution.
• Customer service orientation and ability to de-escalate challenging interactions.

Work Environment / Schedule (editable)

• Position type: Full-time, Salaried
• Work setting: On-site

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