Prior Authorization Knowledge & Policy Specialist

The Authorization Resource Center (RC) is the central hub for all knowledge, processes, and payer policies related to prior authorizations (PAs) across our organization. As a Prior Authorization Knowledge & Policy Specialist, you will gather PA requirements directly from insurance plans, translate them into clear resources and job aids, and support internal teams with accurate, up-to-date guidance. You’ll triage information requests via Jira, partner closely with Market Access and Insurance Billing, and help build a best-in-class knowledge base in a fast-moving, rapidly evolving environment.

KEY RESPONSIBILITIES:

Focus Area: Payer Policy Research & Advocacy

• Contact payers to confirm PA requirements, covered codes, and portal workflows.
• Document findings in standard templates; update configurations in billing/eligibility systems.
• Serve as a subject-matter expert on test-specific authorization criteria and payer nuances.

Resource & Job-Aid Development 

• Create step-by-step guides (job aids) for submitting and obtaining PAs through Availity and other payer portals.
• Maintain a searchable knowledge library covering “which tests require authorization” and “how to configure system flags.”

Ticket Management (Jira)

• Monitor and respond to information-request tickets from clinical, billing, and customer-service teams.
• Prioritize, resolve, and close tickets, ensuring accurate documentation and timely SLAs.

Process Improvement & Education

• Identify recurring pain points; propose workflow changes to reduce denials and turnaround time.
• Train cross-functional stakeholders on new PA policies, resources, and best practices.
• Contribute to ARC team stand-ups and retrospectives, sharing insights and lessons learned.

Change Readiness & Agility

• Thrive in a “build-as-we-go” setting—adapt quickly as payer rules, internal processes, and team structures evolve.
• Proactively surface gaps in knowledge content and help define new processes as the ARC matures.

REQUIRED QUALIFICATIONS:

• Prior Authorization Expertise – 2 + years in PA advocacy, revenue-cycle, or insurance verification (hospital, laboratory, or health-tech setting).
• Payer-Facing Communication – Comfortable calling payer reps to clarify requirements and escalating when necessary.
• Documentation Strength – Proven ability to write concise, step-by-step instructions and policy summaries.
• Process-Improvement Mindset – Experience mapping workflows, spotting inefficiencies, and driving corrective action.
• Technical Tools – Familiarity with Jira (or similar ticketing), MS Office (advanced Excel a plus for code/policy tracking), and common payer portals (e.g., Availity).
• Adaptability & Self-Direction – Demonstrated success in unstructured, fast-changing environments; self-starter who needs minimal oversight.
• Education – Bachelor’s degree or equivalent combination of training and hands-on PA/RCM experience.

PREFERRED KNOWLEDGE & ABILITIES:

• Prior experience building knowledge bases, SOPs, or job-aid libraries from the ground up.
• Exposure to automation/AI solutions in revenue-cycle or health-tech workflows.
• Understanding of CPT/HCPCS coding and its impact on authorization requirements.
• Strong presentation skills for educating diverse internal audiences.