01What the role is measured on#
Every verdict is made of the same five dimensions. Each is scored on its own, so a candidate sees where they are strong and where to work.
- Clinical skillsThe hands-on and judgement work of the role: recognising what matters, acting in the right order, and knowing when something cannot wait.
- Workflow and toolsGetting the work done in a real setting: the systems, records, equipment and handoffs the role runs on, used correctly and on time.
- Patient communicationHow the role talks with patients, families and colleagues: listening, explaining plainly, and confirming what was understood.
- Compliance and safetyThe rules that protect people: privacy, consent, infection control, reporting duties and the safety checks the role is accountable for.
- Role knowledgeKnowing the job itself: what the role is responsible for, where its scope ends, and who to bring in when it does.
02What a ready hire does#
What a competent prior authorization specialist does on day one, dimension by dimension.
Clinical skills
- Finds the clinical facts that meet the criteria, and recognises when the record genuinely does not support the request.
- Selects diagnosis and procedure codes the documentation supports, never the codes most likely to be approved.
Workflow and tools
- Submits complete requests and tracks each against its decision deadline, escalating before the clock runs out rather than after.
- Locates and assembles the supporting documentation from the record without exporting more than is needed.
Patient communication
- Writes to a payer with the criterion, the evidence and the ask stated plainly enough for a reviewer to act on.
- Tells a patient what has been requested, where it stands and what happens next, without jargon or false assurance.
Compliance and safety
- Discloses protected health information to a payer only through an approved channel and only as far as the request requires.
- Sends the minimum record necessary to establish medical necessity, rather than the whole chart for convenience.
Role knowledge
- Reads a denial for its actual stated reason and identifies the specific criterion the submission failed to meet.
- Maps the record to the cited coverage policy point by point, and chooses between a written appeal and a peer-to-peer on the merits.
03Safety red lines#
Any one of these keeps a candidate from Ready Day One, whatever the rest of the score. They are published so nobody meets them for the first time in the assessment.
Would state in a request or appeal a clinical fact the record does not contain, or overstate one - six weeks of therapy when the record shows two visits, a symptom or examination finding nobody documented - or would ask a provider to document something that did not happen, so the request meets the criteria.
A request built on facts the record does not support is a false statement to a payer, which is fraud, and it can send a patient to a procedure the evidence did not justify.
Would change or add a diagnosis or procedure code the documentation does not support because it is more likely to be approved, whether on their own initiative or at a payer's or colleague's suggestion.
Codes chosen for approval rather than for the record make a false claim, a False Claims Act exposure, and leave a diagnosis in the patient's history that they do not have.
Would send protected health information through an unapproved channel, such as a personal email address or an unverified fax number, or would send the whole chart when the request needs only specific records.
Both are disclosures HIPAA does not permit, and records sent to an unsecured address or beyond what was needed cannot be recalled.
Would route a request the ordering provider has marked urgent through the standard queue, or let an urgent request go past its decision deadline or the patient's treatment date without escalating to the payer and the ordering provider.
An urgent request exists because waiting could seriously jeopardise the patient's life, health or recovery, and the delay is the harm.
04Outside the role#
Knowing where the role stops is part of the standard. Going past it is not extra credit.
- Does not decide whether a service is medically necessary, or advise the provider on the clinical plan, beyond matching the documentation to the payer's criteria.Reports which criteria the record meets and which it does not, and leaves the clinical decision to the ordering provider and the determination to the payer's reviewer.
- Does not write, alter or suggest wording for clinical documentation.Tells the provider what the criteria require and what the record does not show, and asks what happened; if care was given but not recorded, the provider adds a dated addendum in their own words.
- Does not choose or change diagnosis or procedure codes to obtain an approval.Submits the codes the documentation supports and sends any mismatch to the provider or coding team as a query.
- Does not hold a peer-to-peer or argue clinical merits with a payer's medical director in the physician's place.Schedules the peer-to-peer for the ordering physician and briefs them on the policy, the criterion in dispute and the evidence in the record.
05How it is assessed#
A spoken assessment
An examiner talks the candidate through realistic cases from this role, and follows up the way a senior colleague would.
Five dimensions
Each answer is read against the expectations above and rated on the same four-level scale.
The 70 bar
Every scorecard shows the score against 70, overall and for each dimension, with the reason for the verdict.
Safety first
Crossing one of the safety red lines holds a pass back, however strong the rest was.
The four levels
- Not yet
- Developing
- Proficient
- Exemplary
06Sources and review#
Drawn from the certification frameworks and practice standards below, and reviewed by clinicians. Version 2, last reviewed .
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)Centers for Medicare & Medicaid Services, 2024
- Prior Authorization API guidanceCenters for Medicare & Medicaid Services, 2024
Cited as sources. Not an endorsement by the organizations named.