Prior Authorization and Referral Management Rep

About the Role

This position coordinates prior authorization and referral processes for patients being referred for services, testing, specialty care, diagnostic procedures, and surgery. The role acts as a liaison between patients and professional staff, facilitating care coordination. Responsibilities include extensive scheduling coordination with surgery departments, specialists, and ancillary departments. The position may be based in a centralized location supported by Patient Access Services or in an outpatient clinic supporting a single specialty.

Responsibilities

• Multitask and prioritize workflows while engaging providers, care teams, and patients in the prior authorization process.
• Confirm and validate patient health plan coverage, obtaining accurate benefit eligibility and coverage.
• Update systems accurately with coverage and benefit information.
• Communicate provider, facility, and order details to health plans as part of the prior authorization and referral process.
• Notify health plans and obtain financial clearance for patient care requiring prior authorization.
• Coordinate and support providers with medication authorizations.
• Coordinate patient assistance programs with patients and providers as needed.
• Utilize internal and external systems to request and coordinate prior authorizations and referrals for patient care.
• Facilitate scheduling of patients with internal and external departments, clinics, and hospitals.
• Update and annotate systems with current and accurate information regarding prior authorization and referral requests.
• Track, update, and investigate current orders and tasks, managing them through the system to ensure accuracy.
• Monitor system referral and authorization work queues to ensure orders are managed, updated, and routed for scheduling.
• Obtain documentation from providers, facilities, and patients to ensure accurate prior authorization and patient assistance requests.
• Communicate effectively with providers, care team members, and patients regarding authorizations, scheduling, insurance benefits, and eligibility.
• Assist with patient education and follow-up regarding prior authorization and referral processes.
• Oversee scheduling and appointments when referrals are required on behalf of the patient.
• Work as part of a care team with providers and clinical staff.
• Support the organization’s vision, mission, and values, as well as Lean principles of continuous improvement.
• Maintain a safe environment for caregivers, patients, and guests.
• Conduct all activities with professionalism and confidentiality.
• Comply with applicable laws, regulations, policies, and procedures, supporting corporate integrity efforts.
• Deliver timely, efficient, and accurate customer service and patient care.
• Perform additional duties of similar complexity as required or assigned.

Requirements

• High School diploma or GED (required).
• College-level coursework (preferred).
• Minimum of one year of experience in a hospital, clinic, or medical insurance billing office, performing duties related to medical billing, pre-authorization, claims processing, or a related area.
• Basic understanding of medical coding.