Prior Authorization Specialist

About Koya Medical

Koya Medical is committed to transforming care for venous and lymphatic conditions through innovative, patient-focused technologies that enhance lives and promote self-care. The organization values integrity, humility, dedication, teamwork, and enjoyment in the workplace. They provide a compensation package consisting of base salary plus bonuses along with competitive benefits.

Role Summary

The Prior Authorization Specialist is responsible for ensuring timely approvals from payers by managing authorizations, precertifications, predeterminations, and referrals. The position aims to maximize reimbursements for patients and the company by educating payers about Dayspring products and applying expertise in insurance procedures across diverse health plans. This is a full-time, exempt position reporting to the Manager of Prior Authorization within the Reimbursement Operations team, and the work is performed remotely.

Key Duties and Responsibilities

• Deliver medical records and supporting documents to payers for coverage approval, including handling network exceptions and single case agreements.
• Assess clinical documentation to verify medical necessity.
• Manage authorizations, precertifications, predeterminations, and referrals across various insurance providers.
• Educate insurance payers on product features and benefits to facilitate coverage and reimbursement.
• Clearly communicate findings from payer processes to internal teams.
• Coordinate with internal departments to confirm accurate patient order handling.
• Adhere to HIPAA regulations and all relevant compliance requirements.
• Maintain accuracy while meeting defined productivity and quality benchmarks.
• Support the creation and refinement of internal workflows and best practices.
• Perform additional tasks as assigned.

Required Qualifications and Skills

• High school diploma is mandatory; associate or bachelor's degree is preferred.
• At least 3 years of experience in prior authorization and reimbursement processes.
• Experience in medical device industries, healthcare reimbursement, or related healthcare fields.
• Comprehensive understanding of insurance processes and authorization workflows.
• Excellent written and verbal communication abilities.
• Exceptional attention to detail with strong organizational and multitasking skills.
• Capability to work independently and collaboratively in a dynamic, fast-paced setting.
• Proficiency in payer portal navigation and Salesforce CRM.
• Demonstrated skill in managing multiple priorities and meeting deadlines under pressure.

Core Competencies

• Effective communication and cultural sensitivity.
• Initiative and critical thinking.
• Adaptability and flexibility.
• Planning and organizational skills.
• Teamwork and collaboration.

Tools and Technology

Familiarity with Google Suite, Microsoft Office Suite, Adobe, and Salesforce CRM is required.

Physical and Work Environment

The role involves regular communication and hearing, frequent use of hands and fingers, occasional standing, walking, sitting, reaching, and occasional lifting or moving objects up to 25 pounds. Vision requirements include close and distance vision with the ability to adjust focus. Work environment noise is generally low to moderate. Reasonable accommodations may be provided for individuals with disabilities.

Additional Information

This job description is not exhaustive and may change at the discretion of management. Employees must follow job-related instructions and may be asked to perform other related duties as needed. The requirements described are minimum qualifications and do not constitute an employment contract beyond an at-will relationship. Koya Medical is an Equal Opportunity Employer, maintaining a drug-free workplace and complying with ADA regulations.

Compensation

The salary range for this full-time remote position in the United States is from $55,000 to $60,000 per year.