JOB SUMMARY:

The Prior Authorization & Billing Specialist is responsible for securing and maintaining accurate Medicaid authorizations, entering palliative visits efficiently and performing other key accounting functions as assigned by the Controller. This role ensures that all prior authorizations and billing activities are completed in compliance with Medicaid guidelines, internal policies, and applicable regulatory requirements. The Specialist works closely with clinical, administrative, and finance teams to support timely reimbursement and accurate financial reporting.

Reports To: Controller
FLSA Status: Non-exempt

Requirements:

ADDITIONAL FUNCTIONS

• Adheres to patient rights, abuse reporting and confidentiality policies
• Attends scheduled staff meetings and/or in-service training
• Adheres to the departmental dress code requirements related to personal grooming and attire
• Participates in Performance Improvement activities as requested
• Demonstrates reliability by making every attempt to report to work on time, providing proper notification for absence or tardiness and follows policies related to time off requests.
• Assumes responsibility for on-going personal development and continuing education
• Follows chain of command, seeking guidance from higher authority as needed

PHYSICAL/SAFETY REQUIREMENTS:

• Prolonged periods sitting at a desk and working on a computer
• Occasional lifting of files or office equipment up to 15 pounds
• Work is performed in an office environment with regular interaction with staff and external payers
• Must have the strength and endurance required to perform all job functions
• Must be able to utilize appropriate basic office equipment
• Must use appropriate body mechanics as needed
• Able to follow the designated plan of action in the event of a fire or other emergency
• While performing the duties of this job, the employee is regularly exposed to fumes or airborne particles and work-related stresses
• Position is a Category 2 for potential exposure to blood/body fluids. (Does not usually require the performance of procedures or other tasks in the work routine that involve exposure to blood, body fluids or tissues, but Category 2 tasks may require the unexpected performance of these procedures)
• The noise level in the work environment is usually minimal
  The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
  In compliance with the Americans with Disabilities Act of 1990, the employer will provide reasonable accommodations to meet the work environmental and physical demands listed above.

QUALIFICATIONS AND EXPERIENCE:

• High school diploma or equivalent required; associate’s degree in accounting, Business, or Healthcare Administration preferred
• Minimum 2 years’ experience in Medicaid billing and prior authorization processing, preferably in healthcare or hospice/palliative care preferred
• Working knowledge of Medicaid rules, claim submission processes, and denial management
• Working knowledge of insurance verification process
• Excellent customer service skills and strong written and verbal communication skills
• Strong attention to detail and accuracy in data entry and documentation
• Proficiency with billing software, Medicaid portals, and Microsoft Office Suite (Excel, Word, Outlook)
• Excellent organizational and time management skills, with the ability to meet deadlines in a fast-paced environment
• Strong verbal and written communication skills, with the ability to work effectively across departments
• Problem-solving skills with a proactive approach to resolving authorization and billing issues
• Ability to research and analyze data
• Ability to work independently with minimal supervision
• Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization
• Proficiency in MatrixCare is desired
• Excellent communication and interpersonal skills
• Ability to work under pressure
• Excellent organizational skills
• Unafraid to ask questions or present concerns