Job Description

Job Title: Senior Authorization Specialist
Job ID: 31314970
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Department: Rev Cyc Care Mgmt
Location: 2 Hot Metal Street, Pittsburgh PA 15203


UPMC is searching for a Senior Authorization Specialist to join their Care Management team.  This role will perform authorization activities for a broader scope of inpatient, outpatient and emergency department patients, denial management and all revenue functions. This role will need to demonstrate, through actions, a consistent performance standard of excellence to which all work is to conform. The expertise of the Authorization Specialist Senior shall include an in depth working knowledge in the area of authorization related activities including pre-authorizations, notifications, edits, denials, across service areas or business units. The Authorization Specialist Senior shall demonstrate the philosophy and core values of UPMC in the performance of duties.

This full time position is based at the Quantum building in Pittsburgh, but has potential to be a work from home opportunity after meeting productivity and training standards.  

  • General responsibilities:
    1.  Maintains compliance with departmental quality standards and productivity measures.  
    2. Works collaboratively with internal and external contacts to enhance customer satisfaction and process compliance, to avoid a negative financial impact.
    3. Utilizes 18+ UPMC applications and payor/ contracted provider web sites to perform prior authorization, edit, and denial services.
    4. Provides on the job training for the Authorization Specialist.
    5. Utilize authorization resources along with any other applicable reference material to obtain accurate prior authorization.
  • Prior authorization responsibilities
    1. Reviews and interprets pertinent medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility. 
    2. Utilizes payor-specific criteria or state laws and regulations to determine medical necessity for the clinical appropriateness for a broad scope of services and procedures considered effective for the patient's illness, injury, or disease.  
    3. Obtains appropriate diagnosis, procedure, and additional service codes to support medical necessity of services being rendered using pertinent medical record and ICD-CM, CPT, and HCPCS Level II resources. 
    4. Submits pertinent demographic and supporting clinical data to payor to request approval for services being rendered. 
    5. Provides referral/pre-notification/authorization services timely to avoid unnecessary delays in treatment and reduce excessive administrative time required of providers.
  • Retrospective authorization responsibilities
    1. Reviews insurance payments and remittance advice documents for proper processing and payment of authorization claims, as appropriate. 
    2. Audits authorization related data errors and/or completes retro-authorizations to resolve unprocessed or denied claims. 
    3. Researches denials by interpreting the explanation of benefits or remittance codes and prepares appeals for underpaid, unjustly recoded, or denied claims. 
    4. Submits requests for account adjustments/controllable losses to manager in accordance with departmental process. 
    5. Identifies authorization related edit/denial trends and causative factors, collates data, and provides summary of observations. Communicates identified trends to Manager.


  • High School diploma or equivalent with four years working experience in a medical environment (such as a hospital, doctor's office, or ambulatory clinic) OR an Associate's degree and two years of experience in a medical environment required. (Bachelor's degree (B.A) preferred) 
  • Completion of a medical terminology course (or equivalent) or has three years of experience working with medical field required
  • Skills Required: 
    • Knowledge and interpretation of medical terminology, ICD, and CPT codes
    • Proficient in Microsoft Office applications 
    • Excellent communication and interpersonal skills
    • Ability to analyze data and use independent judgment
  • Skills Preferred: 
    • Understanding of authorization processes, insurance regulations, third party payors, and reimbursement practices
    • Experience utilizing a web-based computerized system

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $16.72 to $26.54 / hour

Union Position: No

Apply Current Employee?


At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.


Now more than ever, YOU can help us shape our communities and UPMC into a better place for everyone to work, study, play, and thrive.

Learn more about working here and check out our policies and recent updates.

UPMC Health Plan Named Best Places to Work for LGBTQ Equality in 2019

UPMC Ranked #1 Best Places for Women and Diverse Managers in 2019

Talent Network