Healthcare Prior Authorization Coordinator

Healthcare Prior Authorization Coordinator

Non-Clinical

Work Set-up: Onsite - Potential to WFH after training

Location: Valero, Makati City
Schedule: Graveyard | Shifting Hours

Position Summary

The Healthcare Prior Authorization Coordinator is responsible for providing administrative support to the Utilization Management (UM) department by coordinating prior authorization, referral, and utilization review activities. This role serves as the front line for authorization intake, including fax and electronic submissions, ensuring requests are accurately received, documented, routed, and tracked throughout the authorization lifecycle.

The UM Coordinator works collaboratively with providers, members, licensed clinical staff, and internal departments to facilitate timely processing while ensuring compliance with client policies, regulatory requirements, and service level agreements.

This is a non-clinical position. The Prior Authorization does not perform medical necessity reviews, make clinical determinations, approve or deny services, or perform duties requiring clinical licensure.

Essential Duties & Responsibilities:

Authorization & Referral Intake

• Receive, review, and process incoming prior authorization and referral requests.
• Review requests for completeness and identify missing documentation.
• Verify required demographic, provider, and member information.
• Create and maintain authorization records within the client's utilization management platform.
• Prioritize requests according to client-defined urgency and regulatory turnaround requirements.
• Route requests to the appropriate clinical reviewer based on established workflows.
• Track pending requests and perform timely follow-up activities.

Fax Intake & Document Management

• Monitor designated electronic fax queues throughout the assigned shift.
• Retrieve and process incoming authorization, referral, and clinical documentation received via fax.
• Review faxed documentation for completeness, legibility, and required supporting information.
• Index, classify, and upload faxed documentation into the appropriate utilization management or document management system.
• Match incoming documentation to existing authorization requests or create new cases when appropriate.
• Identify duplicate submissions and process according to established procedures.
• Request additional documentation from providers when required.
• Prioritize expedited and urgent requests received via fax in accordance with client policies.
• Maintain accurate documentation of all fax intake activities.
• Ensure all Protected Health Information (PHI) is handled in compliance with HIPAA and client security requirements.

Case Coordination

• Monitor work queues to ensure timely progression of authorization requests.
• Route cases to licensed clinical reviewers according to established workflows.
• Track authorization status through completion.
• Coordinate with internal departments to resolve administrative issues.
• Escalate urgent, incomplete, or complex cases according to established procedures.
• Support workflow management to ensure compliance with turnaround time requirements.

Provider & Member Support

• Incoming and Outgoing Phone Calls
• Communicate with provider offices regarding incomplete requests and required documentation.
• Respond to administrative inquiries regarding authorization status.
• Coordinate retrieval of medical records and supporting documentation.
• Maintain professional communication with providers, members, and internal stakeholders.
• Escalate inquiries requiring clinical review or medical judgment to licensed clinical staff.

Documentation & Data Management

• Document all actions, communications, and case updates accurately within designated systems.
• Maintain complete and accurate authorization records.
• Ensure documentation meets client, regulatory, and audit requirements.
• Assist with data validation and record maintenance activities.
• Maintain confidentiality of Protected Health Information (PHI).

Operational Support

• Monitor assigned work queues and prioritize workload appropriately.
• Support inventory management and workload balancing.
• Participate in process improvement initiatives.
• Assist with implementation of workflow updates and operational changes.
• Support cross-training and knowledge-sharing initiatives.
• Perform other administrative utilization management support activities as assigned.

Compliance

• Maintain compliance with HIPAA, CMS, NCQA, URAC, state regulations, and client policies, as applicable.
• Follow all client Standard Operating Procedures (SOPs) and business rules.
• Complete required compliance, privacy, and information security training.
• Maintain confidentiality of all member, provider, and organizational information.

Preferred Experience

Experience with:

• Utilization Management
• Prior Authorization
• Referral Management
• Fax Intake
• Medical Records
• Provider Services
• Managed Care
• Medicare Advantage
• Medicaid
• Commercial Health Plans
• Quality Assurance
• Root Cause Analysis

Required Qualifications

• High School Diploma or equivalent required.
• Minimum of 1–3 years of experience in healthcare administration, utilization management, prior authorization, referrals, claims processing, provider services, medical records, or care coordination.
• Experience working within a health plan, managed care organization, IPA, TPA, medical group, or healthcare provider environment preferred.
• Knowledge of medical terminology.
• Strong attention to detail and organizational skills.
• Excellent verbal and written communication skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Intermediate proficiency with Microsoft Office applications.

Work Arrangement: This is a full-time position that requires reporting to the office. (There is an opportunity to work remotely if production and attendance qualifiers are met after training, nesting, and ramp are completed) However, please note that this is a performance-based role, and the company reserves the right to require employees to report onsite at any time based on business needs, performance evaluations, operational requirements. Flexibility to transition to an office-based setup when necessary is expected.

Additional Benefits:

• Comprehensive HMO Coverage - Medical & Dental
• HMO coverage on Day 1 plus 1 dependent

COMPANY OVERVIEW

Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers. 

The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans’ members and providers.  The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually.  The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance and automation of claims operations for its clients.

Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.