Prior Authorization Coordinator I

About Moda Health

Moda Health is an Oregon-based organization established in 1955 with a focus on quality care, strong member coverage, supportive employee benefits, and community wellbeing. The company emphasizes diversity and inclusion and encourages candidates who value working in a respectful, equitable environment.

Role Summary

This full-time work-from-home position supports the Medical Management team by researching and assisting with prior authorization requests. The coordinator helps prepare, review, or complete requests as assigned and contributes to timely processing for members, providers, and the clinical team.

Compensation

The hourly pay range for this role is $19.43 to $21.86, depending on experience and qualifications. Candidates who meet only the minimum requirements may be placed at the lower end of the range.

Benefits

• Medical, dental, vision, pharmacy, life, and disability coverage
• 401(k) with matching contribution
• Flexible spending account (FSA)
• Employee assistance program
• Paid time off and company-paid holidays

Required Qualifications

• High school diploma or equivalent
• 1 to 2 years of experience in a medical office and/or insurance setting
• Strong problem-solving ability and sound decision-making skills
• Working knowledge of medical terminology, coding, claims adjudication rules, and provider contracting regulations at state and federal levels
• Understanding of health plan benefits
• Typing speed of at least 35 words per minute and 10-key speed of 135 strokes per minute
• Comfort using a PC and Microsoft Office tools
• Strong written, verbal, and interpersonal communication skills, including business writing and grammar
• Ability to interpret complex benefit structures and contract terms
• Strong organization and attention to detail
• Ability to work independently and collaboratively with staff, members, and providers
• Commitment to confidentiality
• Dependability in arriving on time and working consistently each day
• Ability to manage pressure, interruptions, and changing priorities
• Professional business appearance and conduct

Key Responsibilities

• Investigate and review referral and authorization requests, then process or route them according to the applicable guidelines
• Determine whether prior authorization is needed based on plan type, ICD-10, CPT/HCPC codes, or place of service
• Explain the prior authorization process to members and providers
• Coordinate with provider offices to collect accurate details needed to complete referrals and prior authorizations
• Escalate complex matters to the RN, Manager, or Supervisor as needed
• Support daily administrative work for the clinical team and help ensure deadlines are met
• Use company systems to document interactions with providers and members
• Work with other Medical Management support staff to maintain effective communication
• Review claims and encounters against authorization limits, benefit coverage, and provider contract terms
• Use internal systems to verify eligibility, benefit details, and provider network participation
• Complete approvals and denials issued by the medical director in a professional and constructive manner
• Send correspondence to providers, members, and internal teams when additional information is needed or services are denied
• Check authorizations for accuracy, including maximums, limits, and special instructions
• Follow HIPAA and all applicable privacy, security, regulatory, state, federal, CMS, and Medicaid requirements
• Review personal work for accuracy, consistency, and policy compliance
• Identify issues and help research workable solutions
• Collaborate with the team to maintain workflow, productivity, and compliance standards
• Complete additional assignments and special projects as directed
• Maintain productivity expectations while handling a heavy and complex workload
• Use all applicable policies, procedures, and reference materials to support accurate claims and authorization processing
• Enter data into Facets UM or CT Dynamo and verify member eligibility and provider network participation
• Keep detailed patient notes when a request is not approved, needs more information, or is routed onward
• Perform other related duties as assigned

Working Conditions

This is a remote role that involves extensive computer and keyboard use, prolonged sitting, and frequent phone communication. The job requires working across multiple screens, using a reliable high-speed hard-wired internet connection, and being comfortable appearing on camera for virtual training and meetings. Work may extend beyond the standard schedule, including evenings and occasional weekends, based on business needs.

Contacts

The position involves internal coordination with the team and Customer Service, as well as external interaction with Moda members, PBM vendors, providers, and provider offices.

Equal Opportunity

Moda Health provides equal employment opportunities to qualified candidates regardless of race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or other protected status. These protections apply to all terms of employment, including hiring, pay, promotion, transfer, leave, termination, and training.

Accommodation Contact

Questions about accommodations may be directed to Kristy Nehler or Danielle Baker through the company human resources email address.