RCM Benefits Verification / Prior Authorization Specialist

Salary Range: 60000 to 65000 (Currency: USD) (Pay period: per-year-salary)

What You'll Do

Comprehensive Benefit Verification

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.

2. Prior Authorization Management

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.

3. Payer Pushback & Problem Ownership

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.

4. Provider Communication

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.

5. Self-Management & Technology

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.

Required Experience

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

Nice to Haves

Behavioral health, psychiatry, or mental health billing background
Spravato and/or TMS BV/PA experience
Experience communicating directly with clinicians or practice administrators
Familiarity with AI tools (Claude, Gemini) in a daily workflow
Pylon or comparable ticketing platform experience
Candid Health experience
A/R Follow-Up experience