RCM Benefits Verification – Prior Authorization Specialist
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Job Description
Benefit Verification & Prior Authorization Specialist managing the benefit verification lifecycle for psychiatric treatments. Operating in a remote capacity within the health technology sector.
Responsibilities:
- Conduct thorough phone and portal-based benefit verifications. Once a patient is confirmed as clinically appropriate, you own the VOB from start to finish.
- Determine the details automated checks miss — medical vs. pharmacy routing, code-level coverage, exact deductible/OOP status, coinsurance, coordination of benefits, and prior authorization requirements.
- Translate VOB findings into a clear, actionable summary for the practice. No jargon, no ambiguity — the practice should be able to act on your output without follow-up questions.
- Own the full PA lifecycle for Spravato, TMS, and other treatments: initial submission through approval, with proactive re-authorization so there are never gaps in care.
- Select the right submission channel based on payer and treatment type (CoverMyMeds, Availity, payer-specific portals, fax/phone where needed).
- Monitor status actively. Follow up before things get stuck. On denial, identify the cause and coordinate appeals or peer-to-peer requests with the practice.
- Understand what each payer requires and confirm clinical documentation supports medical necessity before submission.
- When a VOB or PA response doesn't add up, you investigate — you don't just document and move on.
- Call payers back with targeted questions. Cross-reference portal data with phone results. Identify whether the issue is a data error, a policy misapplication, or a legitimate coverage limitation.
- Escalate with context: when you bring an issue to the team, you've already done the legwork.
- Write clear, concise, professional messages to practices. Every benefit summary, PA update, and denial communication should be something a provider can act on without a follow-up call.
- Be the calm, organized voice when a payer outcome is confusing or frustrating. Your follow-through and communication quality are what make a practice feel they're in the best possible hands.
- Manage your own queue. Flag expiring authorizations before they expire. Raise blockers promptly and specifically — don't sit on problems.
- Pick up new platforms quickly and independently. All internal tools are proprietary — you won't have used them before, and that's expected. What we need is the confidence and resourcefulness to learn them.
Requirements:
- 2+ years of hands-on experience in benefit verification and prior authorization (not just claims or cash posting)
- Strong command of VOB vocabulary and mechanics: deductibles, coinsurance, OOP maximums, medical vs. pharmacy routing, PBMs, coordination of benefits
- End-to-end PA lifecycle experience: submission, status monitoring, denial management, appeals
- Experience with major payer portals (Availity, Navinet, Optum, or payer-specific) and pharmacy PA platforms (CoverMyMeds or comparable)
- Clear, professional written English — you can write a provider-facing message that needs zero edits
- Demonstrated ability to learn new technology independently
- US-based, remote-eligible
Benefits:
- healthcare
- dental
- vision
- generous family leave
- FSA/DCFSA
- mental health benefits
- 401(k) plan
- flexible paid time off
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