Referral and Authorization Specialist

About the role

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 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 role is crucial to the organization's financial success and the delivery of a positive provider and patient experience, as timely and accurate processing of referrals and authorizations ensures that patients receive the necessary care without delays, while also optimizing reimbursement.

Responsibilities

• 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.
• Evaluate payer policies to understand authorization and notice of admission policies.
• Communicate the request/status of the insurance referral and/or prior authorization with internal referring provider offices/departments via the EHR.
• Utilize CNE’s EHR to document all work related to obtaining and/or verifying insurance referral and prior authorizations.
• 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.
• Verify the accuracy of the patient’s insurance information to obtain the insurance referral or prior authorization.
• 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.
• Communicate any issues related to obtaining and/or verifying the approval of the insurance referral and/or prior authorization to management.
• 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.
• Explain the Notice of Non-Covered Service Waiver and Notice of Non-Approved Prior Authorization waiver to patients.
• Work and monitor EHR WQ’s and in Basket pools through the workday.
• Perform other duties as assigned.

Requirements

• High School or GED is required.
• Associate degree or Certified/Registered Medical Assistant preferred.
• 5-7 years of experience working in healthcare.
• 3 years of experience processing insurance referral and/or prior authorizations.
• Bilingual preferred.
• Ability to communicate with people of various diverse backgrounds in a sensitive and compassionate way.
• Knowledge of federal regulations related to the No Surprises Act and healthcare billing compliance.
• Excellent presentation, communication, organizational, and customer service skills.
• Strong understanding of payer requirements, authorization processes, insurance, and medical terminology.

Skills

• Specialized knowledge and thorough understanding of Microsoft 365 (formerly Microsoft Office), EHRs (specifically EPIC), and HIPAA.
• Strong listening, communication (written and verbal), and people skills to positively interact with patients and staff at all levels of the organization.
• Strong critical thinking skills with the ability to troubleshoot and resolve issues.
• Always puts patients’ needs first and ensures that quality and safety requirements are met.

About Us

Care New England Health System (CNE) and its member institutions—Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group—is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.