Prior Authorization Specialist

FamilyWell Health is on a mission to transform women’s mental health across the reproductive life-span (fertility → perinatal → menopause) by embedding evidence-based, insurance-covered care into OB/GYN practices and health systems. FamilyWell Health.  As part of the RCM/Operations team, the Prior Authorization Specialist will play a key role in ensuring that care is authorized, reimbursed, and seamlessly delivered, reducing friction for patients and providers alike.

Prior Authorization Specialist

Revenue Cycle / Provider Access & Authorization 

Reports to: Director of RCM / Provider Access 

Location: Remote

The Prior Authorization Specialist is responsible for securing necessary approvals (prior authorizations, precertifications, referrals, etc.) from payers (Medicaid MCOs, FFS, Commercial) so that the care delivered by FamilyWell’s integrated team (therapists, coaches, psychiatrists, OB/GYN partners) is covered and reimbursed. This role sits at the intersection of clinical operations and RCM, supporting both patient access and revenue integrity.

• Validate insurance eligibility and benefits for scheduled services (therapy, psychiatry, CoCM / BHI minutes, add-ons) in advance of patient appointments or program participation.
• Identify services requiring prior authorization (e.g., higher-level behavioral health codes, specialty/add-on CoCM codes like CPT 99492/99493/99494) and initiate timely authorizations.
• Collaborate with provider credentialing/licensing team (your side) to ensure payer panels are active and authorization processes are known for each payer (e.g., TX Medicaid MCO vs FFS, BCBS MA, Harvard Pilgrim, ChampVA).
• Submit documentation and supporting clinical records to payers for authorization requests; track status, follow up, and update internal trackers.
• Maintain authorization logs, expiration dates, and notification to operational teams when authorizations lapse or need renewal.
• Work closely with RCM/Billing and Claims teams to flag services delivered without proper authorization, mitigate denial risk, and support appeals when needed.
• Act as subject-matter expert within FamilyWell for payer-specific authorization rules, prior-authorization triggers, credentialing panel requirements, and coordination between therapy/psych programs and OB clinics (especially dual-billing or CoCM minute overlap scenarios).
• Develop, maintain and refine internal SOPs, cheat-sheets and training materials for authorization workflows (including patient-facing FAQs on high-deductible plans, prior-auth implications, etc.).
• Monitor industry/payer changes (e.g., new electronic prior authorization mandates, form updates) and adapt processes accordingly. For example, awareness of evolving electronic prior auth rules.
• Provide periodic reporting to leadership on authorization volume, turnaround times, denial trends, and opportunities for operational improvement (e.g., reducing time to auth, lowering denial rates due to missing authorizations).
• Act as escalation point for complex authorization cases (e.g., CoCM add-on minutes, cross-clinic billing between FamilyWell and OB partner, high-deductible/high-OOP patient scenarios).
• Uphold compliance with applicable regulations (HIPAA, payer contract rules, state licensure/credentialing requirements) and internal documentation standards.

Education & Experience

• High school diploma or GED required; Associate’s or Bachelor’s degree in health administration, business, healthcare management or related field preferred.
  
• Minimum 2-3 years of experience in healthcare provider services, prior authorization, utilization management, provider access or RCM in a multi-payer environment.
  
• Strong working knowledge of insurance eligibility, authorizations, CPT/HCPCS codes, payer policies (especially behavioral health/CoCM), and EMR/authorization workflow systems.
  
• Experience with payer types including Medicaid MCOs, FFS, Medicare Advantage and commercial insurers.
  
• Experience working in a behavioral health or women’s health setting is a strong plus.
  

Skills & Competencies

• Excellent organizational, time-management and documentation skills; ability to track multiple authorization requests in parallel and follow through to completion.
  
• Strong communication skills – able to interact with payers, providers, internal teams and patients in a clear and professional manner.
  
• Detail-oriented and proactive. Able to identify missing documentation or authorizations before service delivery to prevent denials.
  
• Analytical mindset – comfortable reviewing authorization/denial data, identifying trends, and recommending process improvements.
  
• Ability to translate technical payer policy/authorization requirements into clear internal SOPs and patient-facing communications (consistent with your preference for ready-to-use templates).
  
• Comfort working in remote environment and collaborating across teams (credentialing, billing, care management, operations).
  

• Authorized services > 98% before date of service (or other target as set by leadership).
  
• Time from authorization initiation to approval meets internal SLA (e.g., within 48–72 hours or payer-defined timeframe).
  
• Denial rate related to missing/incorrect authorization remains below internal target (e.g., < 2%).
  
• Internal stakeholders (billing, clinical team, provider partners) express high satisfaction with work hand-off and minimal authorization interruption.
  
• SOPs and training materials remain up to date; staff adoption increase and fewer questions/escalations around authorizations.
  
• Data-driven improvements implemented (e.g., reducing average turnaround time, reducing redundant documentation) and reported quarterly.
  

• Remote
  
• Standard business hours; occasional ad-hoc follow-up with payers or provider offices may require flexibility.
  
• Work is primarily desk/PC-based but requires regular phone/email/payer portal interactions.
  

• Be part of a mission-driven organization tackling women’s mental health and making a meaningful difference across fertility to menopause.
  
• Collaborate with a dynamic, embedded team model (care managers, therapists, psychiatrists, OB/GYN partners) that values operational excellence and patient experience.
  
• Opportunity to build and improve processes, documentation, and workflows—leveraging your strengths in SOP creation, training and high-impact coordination.
  
• Growth opportunity as the organization expands services, payer panels, and geographies.