Referral and Prior Authorization Specialist

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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 Work Shift : Days/No Weekends (United States of America) On Call Required No FTE: 1 Job Type: Full Time (40 Hours/Week)