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, tec