Prior Authorization Specialist / Clinical Authorization Coordinator (Medical / Allied Health Background)

Blue Health is seeking a Prior Authorization Specialist (also known as Clinical Authorization Coordinator, Pre-Certification Specialist, or Utilization Management Specialist) with a medical or allied health science background (non-clinical role) to support our prior authorization process. This role requires applying clinical knowledge to review, evaluate, and process medical service requests to ensure they meet payer requirements.

Key Responsibilities

• Review prior authorization requests for medical services, procedures, and prescriptions.
• Apply clinical knowledge and payer guidelines to assess medical necessity.
• Ensure compliance with HIPAA, CMS, and insurance requirements.
• Coordinate with physicians, pharmacists, and healthcare providers to obtain additional documentation.
• Maintain accurate case records in EMR/EHR systems (Epic, Cerner, Athena).
• Support appeals and denials management when required.

• Background in Nursing, Pharmacy, or Allied Health Sciences (RN, LPN, BSN, PharmD, CPhT, or equivalent).
• Knowledge of ICD-10, CPT, and HCPCS coding systems.
• Strong understanding of medical terminology and payer guidelines.
• Prior experience in utilization management or authorization processes is highly preferred.
• Excellent communication and detail-oriented problem-solving skills.

Qualifications

• Bachelor’s degree in Nursing, Pharmacy, Allied Health, or equivalent clinical field.
• Preferred MBBS, DPT, PharmD.
• Ability to work independently in a fast-paced environment.
• Familiarity with EHR/EMR systems and insurance workflows.