Patient Referral Assistant

About the Role

The Pre-certification/Denials Specialist is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with government and commercial payers. They communicate via the electronic medical record with clinic personnel, providers, and the hospital scheduling department. This role acts as a primary liaison with third-party/managed care insurers to stay informed of the latest changes in pre-authorization referral procedures and handles the review and follow-up of all pre-authorization denials. The position is productivity-driven and monitored for performance measurements.

Responsibilities

• Completes prior authorizations for Pain Management procedures and medications, working with providers, office staff, and outside sources to ensure accurate and timely third-party referral authorizations (40%).
• Reviews chart documentation (EPIC EMR experience preferred) to ensure patients meet medical policy guidelines, prioritizes incoming authorization requests by urgency, obtains authorizations via payer websites or phone, and follows up on pending cases until completion (30%).
• Maintains individual payer files with up-to-date requirements, initiates appeals for denied authorizations, responds to clinic inquiries about payer medical policy guidelines, and confirms accuracy of CPT codes and ICD-10 diagnoses in procedure orders (30%).

Other Duties and Responsibilities

• Handles multiple tasks and stressful situations, including regular public contact and decision-making.
• Communicates verbally in person, on the phone, and in writing.
• Demonstrates competency in Microsoft Windows and participates in further learning opportunities as required.

Qualifications

• High School Diploma or GED.
• Two to four years of medical office experience with knowledge of payer medical policy guidelines.
• Advanced medical terminology, prior authorization experience, and knowledge of ICD-9/ICD-10 and CPT coding.
• Experience within a physician practice, understanding of third-party payer rules, and medical record charting/documentation.
• Clinical experience preferred.
• Proficiency in Windows, Word Processing, medical practice software, and Medic Computer knowledge.
• Experience with database applications preferred.

Skills

• Excellent interpersonal and customer relations skills.
• Ability to work independently with strong organization and prioritization skills.
• Established written and verbal communication skills.

Physical/Mental Requirements

• Exposure to stressful situations, including public contact, trauma, grief, and death.
• Ability to wear personal protective equipment, including latex materials or substitutes.
• Mobility to move freely about the facility and perform job functions.
• Vision and hearing with or without assisted devices.
• Frequent sitting, standing, walking, and postural changes (stooping, kneeling, crouching).
• Some exposure to bloodborne pathogens and infectious materials.
• Ability to handle multiple tasks, work independently, and maintain regular attendance.
• Dexterity for handling, reaching, grasping, fingering, and feeling, with occasional lifting or carrying of 0-10 lbs (0-33% of the workday).