Referral and Prior Authorization Specialist

The Referral and Prior Authorization Specialist coordinates referrals, prior authorizations, and related patient access activities. This position serves as a liaison between patients, providers, payers, and external healthcare organizations to ensure timely access to medically necessary care, accurate documentation, and compliance with payer requirements.

Essential Job Function

- Initiate, review and process incoming and outgoing referrals to specialists, ancillary providers, testing facilities, and community resources.
- Verify insurance eligibility and benefits of patient coverage by third party payers using appropriate eligibility websites to monitor and flag potential coverage issues to patients and providers.
- Determine authorization requirements based on payer guidelines and obtain required referrals, pre-certifications, and prior authorizations by preparing and submitting complete requests with supporting clinical documentation.
- Coordinate referral appointments and procedures in collaboration with patients, payers, and providers, ensuring all required referral and authorization documentation is transmitted to the appropriate internal and external entities.
- Monitor referral and authorization of work queues, follow up with insurers and providers, and maintain detailed documentation of communications and case status.
- Close referral loops by obtaining consultation reports and maintaining accurate, timely documentation within the electronic health record.
- Manage appeals and resolve denied, rejected, or pending referrals and authorization requests.
- Act as a liaison between providers, insurance representatives and patients to address questions and concerns related to referrals and prior authorizations.
- Maintain confidentiality and comply with HIPAA, state regulations, and internal policies

Education

Required: High School Diploma or GED

Preferred: Medical Assistant training, medical office certification, healthcare administration coursework, or related healthcare education

Experience

Required: Two years of experience in a healthcare setting with responsibilities related to patient access, referral coordination, insurance verification, authorizations, revenue cycle, or customer service.

Preferred: Experience working within electronic medical record workflows, referral work queues, and payer portals preferred.

Licensure / Certification Experience

Required:

Preferred:
·  Certified Medical Assistant (CMA)

·  Certified Medical Administrative Assistant (CMAA)

· Applicable healthcare administrative certification