The Referral and Authorization Specialist plays a vital and strategic role in supporting the financial health of the organization by overseeing the referral and authorizations processes for specialty visits and outpatient testing. This position is essential in centralizing and streamlining the authorization workflow, which is integral to the success of the organization’s operations, patient experience, and financial performance. Obtaining timely and accurate authorization information, prior to performing services, reduces claim denials, ensures payer compliance, and establishes better organizational financial outcomes. This position is crucial to the organization's financial success and the delivery of a positive provider and patient experience, as their timely and accurate processing of referrals and authorizations ensures that patients receive the necessary care without delays, while also optimizing reimbursement.
Duties and Responsibilities:
1. Request and obtain insurance referral and prior authorizations via the insurance carrier and/or third-party authorization companies and then track the status within CNE’s EHR.
2. Evaluate payer policies to understand authorization and notice of admission policies.
3. Communicate the request/status of the insurance referral and/or prior authorization with internal referring provider offices/departments via the EHR.
4. Utilize CNE’s EHR to document all work related to obtaining and/or verifying insurance referral and prior authorizations.
5. Work with both internal and external referring provider offices/departments to obtain the necessary information to obtain and/or verify the approval of the insurance referral or prior authorization.
6. Verify the accuracy of the patient’s insurance information to obtain the insurance referral or prior authorization.
7. Communicate via the EHR any issues related to processing the referral (i.e., PCP not updated with the payer, provider documentation not complete) and/or the accuracy of the patient’s insurance information to the referring department.
8. Communicate any issues related to obtaining and/or verifying the approval of the insurance referral and/or prior authorization to management.
9. Manage the start of the external referral process for all CNEMG PCPs, to include submitting referrals, obtaining an approved insurance authorization, and sending all relevant clinical documentation to the external provider.
10. Explain the Notice of Non-Covered Service Waiver and Notice of Non-Approved Prior Authorization waiver to patients.
11. Work and monitor EHR WQ’s and in Basket pools through the workday.
12. Perform other duties as assigned.
Requirements:
1. High School or GED is required, Associate degree or Certified/Registered Medical Assistance preferred.
2. 5-7 years of experience working in healthcare.
3. 3 years of experience processing insurance referral and/or prior authorizations.
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