Prior Authorization Specialist Job at PHIL

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

New

Medical Records and Authorization Specialist

As a member of the Baxter Finance team, you have the critical thinking and analy...

Location

United States , Houston

Salary:

49600.00 - 53000.00 USD / Year

Baxter

Expiration Date

Until further notice

Requirements

High school diploma or equivalent required
Associates degree or higher preferred
3+ years of industry experience in health insurance
Knowledge of Federal, State, and Local regulations, guidelines, and standards, including a working knowledge of HIPAA rules and regulations
Third party payer experience strongly preferred
Experience in reviewing medical records and obtaining third-party payer reimbursement
Exceptional written, verbal, and interpersonal communications
Strong critical thinking and problem-solving skills
Detail orientated and ability to multi-task
Ability to work independently as well as in a team environment

Job Responsibility

Perform Medical Records and Authorization Specialist duties including documentation collection and review, prior authorization and reauthorization submissions
Communicate directly with client medical records depts, patients, healthcare teams, sales teams, and insurance companies
Collaborate cross-functionally with other Cardiology Health teams
Ensure coverage and payer requirements
Gather clinical documentation to support medical necessity for Cardiology devices
Process paper and electronic correspondence, including logging and distribution of payer and patient inquiries
Establish and maintain positive partnerships with sales team and healthcare teams
Review and assess clinical documentation to ensure all applicable coverage criteria requirements are met
Prepare and submit prior authorization initial and renewal requests to all insurance companies
Process authorization decisions from payers timely to streamline and drive revenue

What we offer

Support for Parents
Continuing Education/ Professional Development
Employee Heath & Well-Being Benefits
Paid Time Off
2 Days a Year to Volunteer
Medical and dental coverage that start on day one
Insurance coverage for basic life, accident, short-term and long-term disability, and business travel accident insurance
Employee Stock Purchase Plan (ESPP)
401(k) Retirement Savings Plan (RSP)
Flexible Spending Accounts

Fulltime

Documentation Specialist

Documentation Specialist for a Microsoft software house. Working in a small team...

Location

United Kingdom , Carnforth / Kendal

Salary:

35000.00 - 42000.00 GBP / Year

KnoWho

Expiration Date

Until further notice

Requirements

Prior experience working as a Documentation Specialist, Technical Author, or Document Controller
SharePoint
Excellent communications skills and the ability to transfer technical info into easy to understand terms
Knowledge of SQL, C# and other Microsoft development tools / languages or software development highly beneficial

Job Responsibility

Prepare, review and manage documentation in various formats
Work with internal teams and external stakeholders to provide documentation and information
Provide expertise internally and externally on SharePoint documentation
Ensure conformation to ISO standards

What we offer

Bonus (standard is over 30%)
Annual pay review
Annual cost of living increase to salary
Medical & pension
Work from home 2 days a week
Full home office kit provided

Fulltime

Documentation Specialist

Documentation Specialist for a Microsoft software house. Working in a small team...

Location

United Kingdom , Carnforth / Kendal

Salary:

35000.00 - 42000.00 GBP / Year

KnoWho

Expiration Date

Until further notice

Requirements

Prior experience working as a Documentation Specialist, Technical Author, or Document Controller
SharePoint
Excellent communications skills and the ability to transfer technical info into easy to understand terms
Knowledge of SQL, C# and other Microsoft development tools / languages or software development highly beneficial

Job Responsibility

Prepare, review and manage documentation in various formats
Work with internal teams and external stakeholders to provide documentation and information
Provide expertise internally and externally on SharePoint documentation
Ensure conformation to ISO standards

What we offer

Bonus (standard is over 30%)
Annual pay review
Annual cost of living increase to salary
Medical
Pension
Work from home 2 days a week
Full home office kit provided

Fulltime

New

Senior Care Navigator

You are the trusted first point of contact for our members. Through every intera...

Location

United States

Salary:

55000.00 - 65000.00 USD / Year

Pomelo Care

Expiration Date

Until further notice

Requirements

3+ years of experience in high-touch, patient-facing environments
Proficient in Zendesk (or similar ticketing tools) and Athena (or comparable EHR systems)
Exceptional written and verbal communication skills, with the ability to translate complex healthcare information into clear, empathetic guidance
Proven judgment in handling sensitive issues, escalations, and time-sensitive care needs
Organized, detail-oriented, and energized by managing multiple workflows in a fast-paced environment

Job Responsibility

Act as the initial human touchpoint for patients, managing a high volume of inbound & outbound messages via email and chat
Coordinate essential care logistics, including verifying medical and prescription eligibility, assisting with specialist referrals, and initiating prior authorizations
Triage & properly escalate member concerns using established protocols
Maintain documentation within Zendesk and our Electronic Health Record (EHR)
Partner cross-functionally to identify friction points in the patient experience
Propose and implement improvements to workflows, tools, and member-facing processes

What we offer

Competitive healthcare benefits
Generous equity compensation
Generous vacation policy

Fulltime

Reimbursement Specialist

In this role you will perform Reimbursement Specialist duties for assigned terri...

Location

United States , Saint Paul

Salary:

49600.00 - 68200.00 USD / Year

Baxter

Expiration Date

Until further notice

Requirements

3+ years of industry experience, preferably in health insurance and/or durable medical equipment
Third party payer experience strongly preferred
Exceptional written, verbal, and interpersonal communications
Strong critical thinking and problem-solving skills
Detail orientated and ability to multi-task
Ability to work independently as well as in a team environment
Possess the ability to manage time and prioritize critical priorities
Proficiency in Microsoft Office Software

Job Responsibility

Perform verification of eligibility and benefits to determine coverage and payer requirements
Ensure all benefit information is loaded correctly to reduce rework and allow for clean claims
Gather clinical documentation to support medical necessity for Cardiology products and assess clinical documentation to ensure all applicable prescription, face to face, and coverage criteria requirements are met
Prepare and submit prior authorization requests to insurance companies including commercial payers as well as government payers including Medicare and Medicaid
Process authorization decisions from payers timely to streamline and drive revenue
Negotiate payment rates for letter of agreement to ensure maximum collection potential
Provide a superior customer experience by leveraging ability to discuss payer policies, coverage criteria, benefit limitations, potential cost, or any pertinent product information with patients and healthcare teams
Understand and adhere to all policies for Baxter and 3rd party payers to ensure the highest standards of quality and compliance

What we offer

Medical and dental coverage that start on day one
Insurance coverage for basic life, accident, short-term and long-term disability, and business travel accident insurance
Employee Stock Purchase Plan (ESPP)
401(k) Retirement Savings Plan (RSP)
Flexible Spending Accounts
Educational assistance programs
Paid holidays
Paid time off ranging from 20 to 35 days based on length of service
Family and medical leaves of absence
Paid parental leave

Fulltime

Patient Admin Specialist

Aquent is partnering with a leading healthcare organization dedicated to providi...

Location

United States , Palo Alto

Salary:

35.81 - 39.79 USD / Hour

Aquent

Expiration Date

Until further notice

Requirements

Be authorized to work in the United States
Not require sponsorship of any kind for the duration of the assignment
Be able to work on a W-2 basis. C2C or 1099 is not permitted for this role
Be able to work the schedule of Monday – Friday, 8:00 AM – 4:30 PM
High School Diploma or GED
Demonstrated knowledge of medical terminology
Proficiency with computer systems and software relevant to administrative functions
Excellent verbal and written communication skills, appropriate for a professional setting
Proven ability to deliver exceptional customer service, solve problems efficiently, and manage multiple priorities in a fast-paced environment
Familiarity with Windows-based office software, computers, and operating systems

Job Responsibility

Serve as the primary point of contact for patients, managing front desk operations, check-ins, and check-outs
Warmly greet and welcome patients, assisting with initial questions regarding appointments, payments, and schedules
Operate multi-line phone systems, screening and routing calls, and taking messages for clinical staff and physicians
Ensure all necessary patient verifications and authorizations are complete prior to appointments
Facilitate effective communication with healthcare providers regarding scheduling preferences and urgent patient needs
Provide essential support to providers and patients using various reference documents and tools
Execute diverse administrative tasks, including maintaining information and paging directories, and processing internal forms
Proficiently utilize telephone systems and electronic medical records systems for daily operations
Consistently meet and exceed organizational and department service standards
Address non-clinical patient inquiries and messages, escalating complex issues as needed

What we offer

subsidized health, vision, and dental plans
paid sick leave
retirement plans with a match

Fulltime

Security Vetting Specialist

We are seeking a Security Vetting Specialist to support and process Bulgarian Go...

Location

Bulgaria , Sofia

Salary:

Not provided

Hewlett Packard Enterprise

Expiration Date

Until further notice

Requirements

Prior knowledge and experience with Bulgarian government security vetting
at least 1 year in a similar role is an advantage
Understanding of EU GDPR and the Personal Data Protection Act (PDPA)
Background in roles requiring strict confidentiality and secure handling of sensitive information
University degree preferred
Ability to develop effective working relationships with colleagues, partners, and authorities
Professionalism in handling adversarial or sensitive situations
Strong risk identification and evaluation skills, with capacity for proportionate action
Ability to interpret and apply regulations and guidance to specific activities
Skilled in the use of IT packages, systems, and databases

Job Responsibility

Provide support and process all types of security vetting required by the Bulgarian Government, EU, and NATO (new applications, transfers, extensions, renewals)
Liaise with the Bulgarian Government, particularly the State Commission on Information Security (SCIS), and other security authorities as appropriate
Support the business with advice and guidance in coordination with Government Security Services (GSS)
Maintain physical and electronic vetting records, ensuring timely renewals
Manage record keeping and control of Aftercare Incident Reporting
Attend internal and external stakeholder meetings
Assist applicants and act as SME in collating required documentation for the clearance process, including questionnaires, consents, diplomas, certificates, official notes, medical documentation, and notarized declarations, as mandated by Bulgarian law.

What we offer

Comprehensive suite of benefits that supports physical, financial, and emotional wellbeing
Specific programs for personal and professional development
Flexibility to manage work and personal needs
Inclusive culture that celebrates individual uniqueness.

Fulltime

Prior Authorization Specialist

PHIL

Location:
United States

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 18, 2026

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Job Posted:
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