Medical Billing and Prior Authorization Specialist

About the Job
Pacific Mind Health is an established outpatient mental health practice seeking a detail-oriented, reliable, and compassionate professional to join our virtual team. We are committed to providing a patient-centered healthcare experience built on respect, integrity, teamwork, and exceptional service.

We are seeking an experienced Medical Billing & Prior Authorization Specialist to join our U.S.-based mental health practice. The ideal candidate has at least 3 years of U.S. prior authorization or medical billing experience, strong commercial and Medicare insurance knowledge, and expertise in claims processing, denial management, insurance verification, and prior authorizations.

This role focuses on prior authorizations for our interventional psychiatry treatments (TMS and SPRAVATO® esketamine) and also includes medical billing responsibilities, requiring someone who can manage both processes accurately and efficiently. Responsibilities include processing claims, investigating denials, submitting appeals, following up on outstanding payments, verifying insurance eligibility and benefits, and managing prior authorizations from submission through approval. You will also help resolve authorization denials and monitor authorization expiration dates and service limits to prevent treatment interruptions.

Experience with Transcranial Magnetic Stimulation (TMS) or SPRAVATO® (esketamine) authorizations, including buy-and-bill and specialty pharmacy requests, is strongly preferred but not required. A clinical background (such as nursing, pharmacy, or medical assistant experience) and comfort speaking with patients are also a plus.

This is a full-time remote position, working Monday through Friday, approximately 40 hours per week. Candidates must be available during Pacific Time (PT) business hours.

Key Responsibilities
● Review clinical charts and provider notes, gather medical necessity documentation, and submit complete, accurate prior authorization requests through online insurance payer portals or by phone.
● Verify patient insurance eligibility, behavioral health benefits, coverage limitations, authorization requirements, and applicable payer medical policies.
● Review clinical documentation, diagnoses, treatment history, and supporting records to ensure authorization requests meet payer-specific medical necessity criteria.
● Track pending authorizations in a shared tracking log, record each payer's expected decision timeframe, follow up with insurance companies and specialty pharmacies within that window, resolve outstanding requirements, and communicate approval status and next steps to providers and staff.
● Identify missing or insufficient clinical documentation and coordinate with providers to obtain the information needed to support authorization approval.
● Investigate authorization denials, determine the reason for denial, and coordinate resubmissions, appeals, and peer-to-peer reviews when appropriate.
● Monitor authorization expiration dates, approved service limits, and reauthorization requirements to help prevent interruptions in patient care.
● Coordinate authorization requirements and scheduling considerations with clinical and administrative teams to minimize treatment delays.
● Manage authorizations for our interventional treatments, including Transcranial Magnetic Stimulation (TMS) and SPRAVATO® (esketamine) through both buy-and-bill (medical benefit) and specialty pharmacy (pharmacy benefit) pathways. TMS and SPRAVATO® experience is strongly preferred but not required.
● Process and submit accurate medical insurance claims, monitor accounts receivable, and follow up on denied, rejected, underpaid, and unpaid claims.
● Investigate authorization-related claim denials, correct billing errors, submit appeals, and communicate with insurance companies to resolve payment issues and recover outstanding revenue.
● Understand CPT codes, ICD-10-CM codes, and applicable modifiers relevant to billing and authorization requests.
● Review explanations of benefits (EOBs) and payment records, maintain accurate documentation, and track authorization and billing outcomes.
● Explain patient financial responsibility, collect patient balances, and respond to billing questions professionally and compassionately.
● Maintain patient confidentiality and comply with HIPAA requirements when handling clinical records, insurance information, and billing documentation.
● Communicate effectively with patients, providers, insurance representatives, and team members.
● Perform additional administrative and/or billing responsibilities as assigned.

Qualifications
● 3+ years of recent U.S. healthcare or mental health prior authorization or medical billing experience required.
● Experience with mental health services, psychiatric practices, or specialty healthcare settings strongly preferred; a clinical background (such as nursing, pharmacy, or medical assistant experience) is a plus.
● Strong experience with U.S. commercial and Medicare insurance plans and major insurance carriers.
● Hands-on experience with prior authorizations, including reviewing clinical records, gathering medical necessity documentation, and submitting requests through payer portals or by phone.
● Experience with insurance eligibility verification and prior authorizations for specialty treatments such as TMS or SPRAVATO® strongly preferred.
● Working knowledge of CPT codes, ICD-10-CM codes, modifiers, and medical necessity documentation.
● Ability to review clinical notes and identify documentation needed to support claims and authorization requests.
● Experience with Tebra/Kareo or a comparable EMR and medical billing system.
● Strong computer, organizational, multitasking, and problem-solving skills.
● Working knowledge of HIPAA and patient privacy requirements.
● Excellent verbal and written communication skills in English.
● Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment.
● Reliable high-speed internet connection required.

Additional Skills & Competencies
● Communication: Clear, professional verbal and written (English) communication with patients, providers, and external vendors through phone, email , and virtual platforms.
● Prior Authorization Management: Review clinical charts, gather required medical necessity documentation, and submit complete, accurate prior authorization requests through online insurance payer portals or by phone.
● Clinical Documentation Review: Review provider notes, diagnoses, treatment history, and supporting clinical records to identify documentation needed to meet insurance coverage and medical necessity requirements.
● Insurance Eligibility & Benefits Verification: Verify patient coverage, behavioral health benefits, authorization requirements, treatment limitations, deductibles, copayments, and coinsurance.
● Authorization Follow-Up: Track pending authorization requests, contact insurance companies for status updates, resolve outstanding requirements, and communicate approval status and next steps to the clinical team.
● Denial Resolution & Appeals: Investigate authorization denials, identify missing documentation or unmet payer criteria, and coordinate resubmissions, appeals, and peer-to-peer reviews with providers when appropriate.
● Provider & Team Coordination: Work closely with psychiatrists, therapists, and administrative staff to obtain supporting clinical documentation and prevent unnecessary delays in treatment.
● Authorization Tracking & Compliance: Maintain accurate records of authorization submissions, approvals, denials, expiration dates, and approved service limits while protecting patient confidentiality in accordance with HIPAA requirements.
● Billing & Reimbursement Support: Identify authorization-related claim denials, research payer requirements, and coordinate resolution to help ensure timely reimbursement.
● TMS & SPRAVATO® Authorization Support: Manage prior authorizations for Transcranial Magnetic Stimulation (TMS) and SPRAVATO® (esketamine), including buy-and-bill and specialty pharmacy requests. Familiarity with TMS and SPRAVATO® coverage policies and medical necessity criteria is strongly preferred but not required.
● Self-Motivation & Accountability: Proactive, dependable, and comfortable working independently in a remote healthcare environment. Takes ownership of authorizations and billing issues, works out the right payer forms, portals, and submission steps independently, follows through on pending requests and outstanding claims, and communicates potential problems promptly.
● Tech Proficiency: Comfortable using:
o Electronic Medical Records (EMR) systems (e.g., Tebra, Kipu, DrChrono)
o Google Workspace (Docs, Sheets, Drive)
o CRM, phone system and workflow management tools (e.g., Asana, HubSpot, Dialpad)
o Dropbox and other secure document management tools
● HIPAA Compliance: Working knowledge of HIPAA requirements and the ability to safeguard protected health information (PHI), maintain confidentiality, and follow appropriate privacy and security procedures when handling sensitive mental health records and billing information.
● Teamwork & Adaptability: Ability to collaborate effectively with clinicians, administrative staff, and billing team members in a busy mental health practice while adapting to changing priorities and maintaining a positive, patient-centered approach.
Application Instructions
If you are interested in this opportunity, we kindly ask that you submit a brief video introduction that includes:
● A short introduction about yourself.
● Your current role or professional background.
● An overview of your U.S. prior authorization and medical billing experience and the insurance companies you have worked with.
● A specific prior authorization you obtained (ideally for a specialty medication or procedure, such as TMS or SPRAVATO®): how you gathered the medical necessity documentation and how you tracked the req