Prior Authorization Specialist

About Us Modena Health ("MH") and Modena Allergy & Asthma ("MAA") are leading and rapidly growing medical practices specializing in allergy, asthma, and immunology care, with clinics across Southern California and Arizona—and ambitious plans for national expansion. We are physician-led, hospitality-focused, and technology-enabled, committed to transforming allergy care while advancing clinical research and expanding access to cutting-edge medicine. Known for our high standard of excellence, we provide compassionate, patient-centered care for both pediatric and adult patients. Our model combines hospitality-driven service with innovative technology solutions that streamline operations, improve clinical outcomes, and enhance the experience for both patients and providers. At Modena, we aim to hire great people, treat them well, and help them find meaning and purpose in our mission. Our dedicated team values collaboration, positivity, and growth while striving to improve lives through expert diagnosis, treatment, and research. We are looking for high-energy, kind, and collaborative individuals eager to grow personally and professionally while making a meaningful impact in the lives of others. Position Summary We are seeking a detail-oriented and proactive Prior Authorization (Buy and Bill) Specialist to join our clinic team. In this role, you will manage the end-to-end process of purchasing, administering, and billing medications to ensure efficient operations, compliance, and optimal patient care. You will handle scheduling, inventory management, authorization processes, and reimbursement monitoring while collaborating on innovative tech solutions and supporting site expansions. This position requires strong organizational skills, knowledge of healthcare billing practices, and the ability to work in a fast-paced medical environment. This is a full-time, non-exempt (hourly) position, scheduled for 40 hours per week. Work hours may vary based on assigned clinic location, Monday through Friday. This role will be based primarily in our La Jolla and Solana Beach clinics but may also provide support to other nearby locations within San Diego County. The ideal candidate is adaptable and enjoys collaborating across multiple sites to ensure seamless operations and excellent patient experiences. Key Responsibilities • Schedule appointments and times for patients to receive their medications, coordinating with clinical staff to ensure timely and appropriate administration. • Track medication inventory levels, monitor stock to prevent shortages, and initiate purchasing orders as needed to maintain adequate supplies. • Monitor medication prices from suppliers, negotiate favorable terms when possible, and identify cost-saving opportunities to optimize clinic expenses. • Ensure prior authorizations are obtained on time and completed accurately, reviewing documentation for compliance with insurance requirements. • Monitor reimbursement and billing success rates, analyze denials or discrepancies, and collaborate with billing teams to resolve issues and improve collection processes. • Implement checks to prevent patients from receiving medications too early, adhering to prescribed intervals and regulatory guidelines. • Verify that all necessary authorizations are in place prior to medication administration, minimizing risks of non-reimbursement or compliance violations. • Collaborate with external tech companies to develop and implement high-tech solutions for automating buy-and-bill processes, including inventory tracking, scheduling, and authorization workflows. • Assist in setting up new clinic sites by managing Health Insurance Numbers (HINs), drafting and negotiating contracts with suppliers and insurers, and ensuring seamless integration of buy-and-bill operations. • Develop and maintain nurse protocols, Standard Operating Procedures (SOPs), and Quality Improvement (QI) initiatives related to medication management and billing to enhance efficiency and patient safety. • Additional duties as assigned. Qualifications & Requirements • Education: Bachelor's degree in healthcare administration, business, or a related field; relevant certifications (e.g., Certified Medical Assistant or Billing Specialist) preferred. • Experience: • 2+ years of experience in healthcare administration, medical billing, or inventory management, with familiarity in buy-and-bill processes for medications. • Strong understanding of insurance prior authorizations, reimbursement policies, and healthcare compliance regulations (e.g., HIPAA, Medicare/Medicaid guidelines). • Proficiency in medical software systems, inventory management tools, and Microsoft Office Suite; experience with automation or tech integration projects is a plus • Skills & Abilities: • Excellent organizational and multitasking skills, with the ability to prioritize tasks in a dynamic environment. • Strong communication and negotiation abilities for working with vendors, tech partners, insurers, and internal teams. • Attention to detail and problem-solving mindset to handle complex billing and authorization scenarios. • Ability to work independently and collaboratively in a team-oriented settings. Compensation The hourly range for this position is $22.00-30.00/hour. The actual compensation for this role will be determined by a variety of factors, including but not limited to the candidate's skills, education, and experience. Physical Requirements Ability to stand, walk, and move throughout the clinic, if applicable, for extended periods; occasionally lift objects up to 25 lbs., bend, stoop, or reach as needed. Frequent use of hands and fingers for patient care and equipment operation. Must have normal (or corrected) vision and hearing and be able to respond quickly in a fast-paced clinical environment, if applicable. What We Offer • Competitive salary and benefits package, including medical, dental & vision insurance, 401(k) retirement plan with employer matching, and professional development opportunities • In addition, we offer paid time Off (PTO), sick time, floating holiday and holiday pay • Opportunity to shape the future of a thriving allergy and asthma practice in beautiful San Diego (and across our expanding network) • A supportive, mission-focused culture where your contributions directly impact patient outcomes and team growth If this role excites you, please submit your resume and a cover letter outlining your relevant experience and why you're passionate about joining our team. We look forward to hearing from enthusiastic candidates ready to drive our success! California Consumer Privacy Act (CCPA) Notice Modena Health ("MH") and Modena Allergy & Asthma ("MAA") complies with the California Consumer Privacy Act ("CCPA"). Personal information provided in the job application process will be collected, used, and retained in accordance with applicable privacy laws. Candidates may request additional information regarding the categories of personal information collected and the purposes for which it is used during the hiring process. Apply tot his job Apply To this Job