Clinical Pathology - Do Not Use

Customer Service Prior Authorization Specialist

2 weeks ago
Regular Full-Time
First shift


Position Summary: Responsible for reviewing accessions for tests requiring prior authorization from the insurance company, coordinating with clients and insurance carriers to obtain prior authorizations as needed per coverage.  Provides accurate and timely information to supporting CPL departments, clients, patients, and the Accounts Receivable(AR) department. Adheres to departmental policies and procedures to include timely submission and follow-up on pending requests as well as notification of status to appropriate AR department.  Able to handle additional delegated work by the leadership team.


Scope:  Promotes quality client/patient relations and creates a supportive climate by serving as a role model for other employees.  Respects and maintains the confidentiality of laboratory and financial information.  Practices and adheres to all company policies and regulations.


Principle Responsibilities:


  1. Utilizes billing and clinical resources and customer service skills to effectively and efficiently triage for prior authorization requirements
  • Utilizes resources to identify accessions with testing that may require prior authorization
  • Review requisition to determine billing information, including insurance carrier
  • Review insurance requirements to determine if prior authorization is required
  • Coordinate with client to obtain needed medical documentation
  • Ability to accurately complete the necessary paperwork to submit prior authorization request to insurance via phone, fax or website
  • Timely follow-up with insurance carriers on pending prior authorization requests
  • Timely notification of appropriate AR department of prior authorization status
  • Understands and operates computer resources proficiently.
  • Ability to positively meet the needs of CPL patients and clients through professional
  • Ability to work with copy machine, fax machines, printers, and other equipment
  • Ability to work with the reference laboratory and CPL laboratory operations to include Patient Service Center personnel, referral sendout department, and any participating entity to complete process.                                                                                                                                                                


  1.  Utilizes computer resources with multiple systems including but not limited to Prior Auth Database, Misys Lab, MS Office, and on-line resources to effectively and efficiently organize, track and submit prior authorization requests
  • Follows procedures for review, documentation and submission for prior authorization
  • Ability to accurately complete the necessary paperwork for appropriate action
  • Understands and operates computer resources proficiently
  • Ability to positively meet the needs of CPL patients and clients through professional communication



  1. Utilizes job knowledge, judgment, and problem solving skills to ensure quality and timely submission and follow-up for prior authorizations
  • Follows established policies and procedures for reviewing and submitting prior authorization requests
  • Identifies problems which may adversely affect the process or customer service and takes appropriate action, including supervisor notification.
  • Understands and follows all CPL policies.
  • Understands and follows all HIPAA guidelines.
  • Participates in departmental Customer Service Meetings.
  • Follows Compliance procedures and participates in Compliance training.



  1. Effectively utilizes departmental resources                                                        
  • Demonstrates efficiency by processing prior authorization submissions promptly and determining priority based on the situation.
  • Utilizes appropriate supplies with minimal waste.
  • Utilizes slow times constructively.
  • Cross-trains to assist with other tasks as necessary, including faxing, critical/alert notifications, add-on data entry/processing, and/or patient record requests


  1. Utilizes personal and professional skills to promote excellent customer service.
  • Communicates with cpl staff and its customers to ensure quality.
  • Maintains and supports a service oriented relationship with internal and external customers.
  • Respects and protects the confidentiality of information relative to patients and clients.
  • Strives to preserve a positive work environment by helping the motivational committee




Minimum – High School diploma or equivalent (GED)

Preferred – Associates degree in the healthcare related field or laboratory or Medical Assistant training




Minimum – 1 year medical insurance and laboratory experience.

Preferred – 2 years or more of Customer Service experience and Medical or Billing experience.


Skills: Excellent customer service and communication skills.  Knowledge of insurance contract/policy. Analytical and problem-solving skills.  Ability to cope with varied levels of workload and multiple tasks.  Ability to adapt to changing work environment.  Able to type at least 35 wpm and have at least an 88% accuracy rate.


Reporting Relationships:  Reports to the Customer Service Supervisor, Assistant Supervisor or other designated person.


Physical Demands:  Requires sitting or standing for long periods of time in a small cubicle or requires walking for long periods of time within the company.  Requires manipulation of tools, objects, and equipment using the following physical motions:  pushing, pulling, lifting, reaching above shoulder height, grasping with one hand or both, extensive typing, twisting and reaching.  Routinely requires coordination of two or more physical operations.  Requires ability to hear audible sounds via headset or telephone handset.


Environmental Demands:  Works in a temperature controlled environment.  Works in a small, noisy environment.  May be required to operate fire and safety equipment or follow other safety procedures in an emergency situation.  May be required to work with time constraints and crisis situations.

Additional Information



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