Before a US patient gets an MRI, a planned surgery or an expensive medicine, their insurance company often wants to approve it first. If nobody gets that approval, the claim is likely to be denied later, and the provider may not be paid at all. The people who get those approvals in time are prior authorization associates.
It is one of the most practical front-end roles in US healthcare, and a good fit for candidates with a science, pharmacy or nursing background as well as experienced BPO professionals. This guide explains the full process, the skills employers want and how to prepare for the interview.
Why prior authorization exists
Payers use prior authorization to confirm that certain services are medically necessary and covered before they are performed, especially costly or frequently overused ones. Common examples include advanced imaging (MRI, CT, PET scans), planned surgeries, inpatient admissions, some specialty drugs, durable medical equipment, and certain therapies. Each payer and plan has its own list, which changes over time.
The prior authorization process, step by step
- Receive the order: the provider schedules a service that may need approval.
- Check requirements: using the payer’s website, portal or phone line, confirm whether authorization is required for this service, code and plan.
- Verify eligibility and benefits for the date of service.
- Collect clinical information: diagnosis and procedure codes, doctor’s notes, test results, previous treatments tried.
- Submit the request through the payer portal, fax, phone or an authorization platform.
- Follow up on pending requests and respond to requests for additional information.
- Record the outcome: approval with authorization number, approved dates and units; or denial with reason.
- If denied: inform the provider; options may include a peer-to-peer review between doctors or an appeal.
Voice and non-voice prior authorization
| Voice | Non-voice | |
|---|---|---|
| Work | Calling payers to check requirements, submit or follow up requests | Submitting through portals and fax, documentation, tracking |
| Key skills | Clear communication with US representatives, note-taking | Accuracy, reading clinical notes, system navigation |
| Shift | Usually US hours | Often US hours, sometimes day shift |
Skills employers look for
- Medical terminology and basic understanding of diagnoses and procedures; science, pharmacy and nursing backgrounds help.
- Knowledge of codes: ICD-10-CM, CPT and HCPCS at a reading level.
- Payer awareness: how Medicare, Medicaid and commercial plans differ.
- Attention to detail with dates, units and codes.
- Communication for voice roles and when coordinating with provider offices.
- Time management: urgent requests have short turnaround times.
- HIPAA awareness, because you handle clinical information. See HIPAA and PHI basics.
Tools you may use
Payer portals and multi-payer portals, electronic health record (EHR) or practice management systems, fax and document management tools, authorization tracking sheets and the client’s ticketing or workflow system.
Interview questions
What is prior authorization?
Approval from the payer before a service is provided, confirming it is medically necessary and covered under the patient’s plan.
What is the difference between a referral and a prior authorization?
A referral is a primary care doctor’s approval for a patient to see a specialist, required by some plans. A prior authorization is the payer’s approval for a specific service.
What details do you record after an approval?
Authorization number, approved codes, number of units or visits, approved date range, servicing provider and facility, and the name of the representative or portal reference.
What is retro-authorization?
An authorization requested after the service, which some payers allow in limited situations such as emergencies. It is not guaranteed.
What is a peer-to-peer review?
A discussion between the treating doctor and the payer’s medical reviewer, often used after an authorization denial to explain medical necessity.
What happens if authorization is missed?
The claim is likely to be denied (for example with CO-197), and the provider may lose the payment or need to appeal.
Career growth
Prior authorization associates can grow into utilisation management support, clinical review support (especially with nursing backgrounds), quality and training roles, or move across to denial management and coding. See career growth in US healthcare RCM.
Frequently Asked Questions
What does a prior authorization associate do?
They check whether payer approval is needed, collect clinical information, submit authorization requests, follow up and record approvals or denials before services are provided.
Is prior authorization a voice or non-voice process?
It can be either. Some roles call payers; others submit requests through portals and fax. Many roles combine both.
Who is eligible for prior authorization jobs?
Graduates are commonly hired, and science, pharmacy, nursing and other healthcare backgrounds are often preferred because the work involves clinical information.
What is the difference between pre-authorization and pre-certification?
The terms are often used interchangeably. Pre-certification is commonly used for hospital admissions and some procedures.
What denial code is used for missing authorization?
CO-197 is commonly used when pre-certification or authorization is absent.