Prior Authorization & Benefits Verification Specialist

COMPANY OVERVIEW

At Bloomwell Autism Therapy, we help children with autism bloom and grow by providing high-quality ABA therapy in a nurturing and supportive environment. We are devoted and compassionate, multi-disciplinary group of clinicians that is creating a world where every child with autism gets the care and support they deserve. Energized by our mission to offer life-changing services to children and families affected by autism and unparalleled opportunities for our team across America, we are dedicated to advancing the state of autism care through best-in-class training, innovative treatment models and meaningful outcomes measurement.

POSITION OVERVIEW

• Location: Work From Home
• Work Schedule:Monday to Friday, 8:00 AM – 5:00 PM CST | 9:00 PM - 6:00 AM MNL
• Holidays: U.S. Holidays

KEY RESPONSIBILITIES

Prior Authorization

• Collect and organize clinical documentation required to support prior authorization (PA)
• requests, including assessment reports, treatment plans, and physician orders.
• Submit PA requests to commercial insurers, Medicaid managed care organizations, and state Medicaid programs across all operating states.
• Monitor authorization status and proactively follow up with payers to ensure timely approvals.
• Track authorization end dates and initiate re-authorization requests well in advance of
• expiration.
• Maintain accurate records of authorization numbers, approved units, service codes, and effective dates in the EMR and relevant tracking systems.
• Communicate PA status updates to clinical and scheduling teams to prevent service disruptions.
• Appeal denied or insufficient authorizations in coordination with clinical staff and leadership.

Benefits Verification & Eligibility

• Conduct thorough insurance eligibility and benefits verification for all new patient inquiries, including coverage type, deductibles, copays, coinsurance, out-of-pocket maximums, and ABA-specific benefit limitations.
• Verify active coverage and eligibility at intake and on an ongoing basis for existing patients.
• Accurately document benefit details in the EMR and communicate findings to the care coordination and billing teams.
• Identify and flag patients with coverage gaps, coverage changes, or secondary insurance considerations.

Documentation & Compliance

• Maintain organized, complete, and audit-ready records for all authorization and eligibility activities.
• Follow payer-specific documentation requirements and stay current on policy changes across all contracted health plans.
• Support internal audits and payer audits by providing requested documentation in a timely manner.
• Adhere to HIPAA and all applicable state and federal regulations governing protected health information.

Cross-Functional & Special Projects

• · Contribute to operational improvement initiatives, including workflow redesigns, system implementations, and process documentation projects.
• · Support onboarding of new clinic locations by helping establish payer credentialing and PA workflows in new markets.
• · Assist leadership with ad hoc research, reporting, and analysis related to payer policy, authorization trends, or operational performance.
• · Collaborate cross-functionally with clinical, scheduling, billing, and leadership teams as needed.

CANDIDATE PROFILE

NICE TO HAVES

• Experience with ABA therapy, behavioral health, or pediatric services.
• Multi-state insurance experience, particularly in Medicaid or Medicaid managed care environments.
• Experience working in a high-growth or multi-site healthcare organization.

QUALIFICATIONS

• 2+ years of experience in prior authorization, benefits verification, or a closely related healthcare revenue cycle role.
• Demonstrated knowledge of commercial insurance and Medicaid payer processes, including authorization workflows and eligibility verification.
• Strong organizational skills with the ability to manage a high volume of tasks with competing deadlines.
• Proficiency with EMR/EHR platforms and payer portals.
• Excellent written and verbal communication skills.
• High attention to detail and commitment to documentation accuracy.