Registration Representative/Preauthorization Representative

Key Responsibilities

• Authorization Verification: Review scheduled procedures and diagnostic services to confirm appropriate payor authorization is obtained and that the service aligns with the payor’s medical policies.
• Documentation Review: Validate the presence of a valid physician order and ensure all necessary clinical documentation requirements are met.
• Referral Coordination: Coordinate physician referrals for additional services, when deemed appropriate, to support patient care and continuity.
• Scheduling Support: Schedule and coordinate services as ordered by physicians, ensuring preauthorization is completed where required.

Skills & Qualifications

• Knowledge of medical terminology, insurance preauthorization processes, and payor requirements.
• Ability to interpret and verify clinical documentation.
• Strong organizational and communication skills.
• Experience with electronic health records (EHR) and scheduling systems preferred.

Qualifications

• Education and Experience Requirements: High school diploma or GED required. Previous experience in customer service required. Knowledge of medical service coding preferred. Familiarity with medical terminology or willingness to learn.

Environmental Factors

• Work is performed in a standard office environment with minimal exposure to unpleasant, irritating, or hazardous conditions.

Physical Demands

• Regularly required to sit, stand, and move through an office environment.

Mental Demands

• Must be able to work under stress and adapt to changing conditions.
• Must meet strict time deadlines and work efficiently under pressure.
• Able to maintain strict confidentiality is essential.

Core Competencies and Skill Requirements

• Communication & Interpersonal Skills: Demonstrates excellent verbal and written communication skills. Maintains strong interpersonal relationships with coworkers, patients, and providers. Uses appropriate communication methods for different situations.
• Organization & Attention to Detail: Able to organize work independently and manage time effectively. Strong attention to detail and accuracy is essential.
• Technical Skills: Above average computer skills, including proficiency in Microsoft Word, Excel, and scheduling or preauthorization software applications.
• General Skill Requirements: Adaptability: Adjusts well to change; handles competing demands and shifting priorities with professionalism; works under irregular schedules and occasional unscheduled overtime. Attendance & Punctuality: Arrives to work and appointments on time; keeps absences within acceptable guidelines; ensures responsibilities are covered during absences. Cooperation & Teamwork: Works well with others; maintains a positive attitude; demonstrates tact and consideration; assists coworkers as needed. Job Knowledge: Competent in job-specific knowledge; keeps current with industry developments; requires minimal supervision. Judgment & Decision-Making: Makes sound decisions in a timely manner; involves appropriate individuals in the decision-making process; respects confidentiality at all times. Problem Solving: Identifies issues proactively; analyzes situations; develops and implements effective solutions; collaborates in group problem-solving. Quality & Productivity: Demonstrates a commitment to accuracy and excellence; seeks feedback to improve performance; meets or exceeds productivity goals. Concentration: Maintains focus and accuracy for extended periods; stays alert to changing conditions or variations. Supervision: Capable of working independently or with minimal supervision; may train or review the work of others as necessary.

Prior Authorization & Liaison Duties

• Understands and applies payor-specific prior authorization requirements, staying up to date with policy and procedural changes from insurance providers.
• Serves as a liaison between hospital staff and physician offices, ensuring accurate communication of outpatient diagnostic service needs and referral information.
• Acts as a key contact for Utilization Review and Patient Financial Services, offering accurate and timely information as needed.

Coordination & Documentation

• Serves as a key contact for Utilization Review and Patient Financial Services, offering accurate and timely information as needed.
• Coordinates physician referrals on appropriate patient accounts, ensuring additional services are authorized and scheduled as needed.
• Schedules, coordinates, and pre-authorizes all necessary services as ordered by physicians.
• Manages incoming phone calls professionally and efficiently to support departmental objectives and customer service expectations.
• Prioritizes scheduled patients in compliance with managed care preauthorization requirements and medical necessity protocols.
• Accurately documents all relevant case information using the account note function, including: Telephone conversations Consultations Authorization details Reference numbers Case rationale

Customer Service & Training

• Maintains a high level of customer service by following internal quality standards and confidentiality policies.
• Communicates regularly with case managers, physician offices, and nurses to secure necessary approvals and updates on patient accounts.
• Maintains accurate and current records of insurance and pre-authorization details.
• Identifies and communicates barriers to service or process improvement opportunities to management.
• Assists in the training of new personnel and supports implementation of new workflows or procedures.