Prior Authorization Specialist

***This position is open through Friday October 17 2025.***

The Redding Rancheria is seeking a Prior Authorization Specialist.

JOB SUMMARY:

The Prior Authorization (PA) Specialist is responsible for coordinating and securing insurance authorizations for medical services procedures referrals and medications across Redding Rancheria Health System (RRTHS). This role ensures timely and accurate submission of prior authorization requests to optimize patient access minimize delays in care and support best patient outcomes.

REQUIREMENTS/MINIMUM QUALIFICATIONS:

1. Masters degree in Business Administration (MBA) Healthcare Management (MGA) or related field is strongly preferred.
2. Bachelors degree in Healthcare Administration Nursing or related health field is required (must possess licensed nurse credentials).
3. Minimum 5 years of experience in a healthcare setting with a focus on nursing supportive services (e.g. care coordination case management patient advocacy clinical liaison).
4. Experience across multiple care environments (hospital clinic outpatient rehabilitation or home health) is strongly preferred.
5. Experience with electronic health records (EHR) and conducting chart reviews.
6. Knowledge of medical terminology required. Must be able to communicate with medical staff effectively.
7. Must be able to multi-task- handle multiple cases directions projects and ability to complete the follow-through.
8. Prior experience in prior authorization utilization review or revenue cycle operations is highly desirable.
9. Excellent interpersonal skills with exceptional professional work ethics consistent with RR guiding values.

ESSENTIAL JOB DUTIES:

1. Initiate and manage prior authorization requests for a broad range of services including diagnostic imaging procedures durable medical equipment (DME) and specialty medications.

2. Collaborate with providers nurses pharmacists applicable departments and insurance carriers to gather and submit appropriate clinical documentation supporting authorization requests.

3. Monitor authorization status and follow up proactively to ensure timely approvals reducing treatment delays and denials.

4. Maintain expert-level knowledge of payer-specific guidelines and authorization workflows for commercial Medicare and Medicaid plans.

5. Communicate authorization outcomes to patients and providers offering clear guidance on next steps or alternative care pathways as indicated/needed.

6. Escalate and assist with appeal process for denied requests in collaboration with clinical teams utilizing appropriate clinical justification and evidence-based standards.

7. Use electronic health records (EHR) to document authorization activity ensuring accuracy and regulatory compliance.

8. Act as a liaison between care teams to support patient navigation access and continuity of care across healthcare settings.

9. Support process improvement initiatives aimed at streamlining the prior authorization process and enhancing the patient experience.

10. Participate in team meetings in-services and professional development opportunities.

11. Assist in developing and updating internal workflows reference materials and training tools related to prior authorization.

12. Provide backup support to other care coordination functions during periods of high volume or staffing gaps.

13. Engage in special projects audits or performance improvement initiatives as requested by leadership.

14. Support onboarding and mentorship of new team members.

15. Works on assigned projects/tasks under the direction of the Director of Nursing.

A completed Redding Rancheria job application must be submitted in order to be considered for employment. You can fill out an application online at please fax ) or email ().

All certifications credentials/licenses education verification /degrees and/or transcripts and Indian verification are required to process your application.

Indian preference applies but we welcome all applicants who wish to apply for this position. Certification of Native American heritage needs to be attached to the job application.

Any offer of employment is conditioned upon the successful completion of a pre-employment drug screen and criminal background screening clearance. All employees are required to submit to a Tuberculosis test (TB) test after they are hired in addition to being tested annually.

Additional Information:

In addition Redding Rancheria offers an excellent benefit package containing Medical Dental Vision Life Insurance and Short/Long Term disability paid holidays vacation and sick leave as well as a generous 401(k) retirement plan.

Redding Rancheria is a federally recognized Tribe with Pit River Wintu and Yana people where pride in Tribal culture history and identity is evident internally and in the larger community. Redding Rancheria is a leader in the constructive development of its people the larger Indian community and the Redding region.

E-Verify Statement

Redding Rancheria participates in the Electronic Employment Verification Program. Visit the E-Verify URL below for more information.

further information please contact Human Resources Dept. at .