Specialty Clinic Referral Specialist & Prior Authorization Coordinator

Description

POSITION TITLE:  Specialty Clinic Referral Specialist & Prior Authorization Coordinator 

Mission of Department: To provide Mission of Department and complete essential functions

listed below.

Purpose of Position:  The referral specialist & prior authorization coordinator is responsible for managing and securing prior authorizations from the insurance providers for medications, diagnostic tests, procedures, and specialist referrals ordered within the specialty clinic. They will assist with referrals to and from the specialty clinic, as well as scheduling specialty clinic appointments. 

Essential Functions:

1. Complete all tasks given daily to referral specialist.

2. Schedule appointments for testing, doctor consultations and other duties as requested by the Specialty Clinic Staff.

3. Prepare needed records and imaging studies to be sent to specialists to which patient is being referred.

4. Record and inform patients of appointments scheduled in referral.

5. Relay and record any problems associated with referrals or patients back to Specialty Clinic Supervisor.

6. Complete tasks given daily and be able to prioritize them in order of urgency.

7. Obtain prior authorizations for specialty medications, procedures, imaging, and referrals in compliance with payer requirements.

8. Review clinical documentation to support the need for prior authorization and ensure completeness prior to submission

9. Submit Prior authorization requests to insurance companies via portals, fax, or phone and track progress.

10. Monitor and follow up on pending authorization to ensure timely approval.

11. Document authorization status and outcomes in EMR system.

12. Notify clinical staff and patients of authorization status outcomes or delays and assist with appeals or alternative coverage when needed.

13. Maintain knowledge of insurance payer requirements and stay updated on changes and authorization policies.

14. Provide support and education to staff and patients regarding the prior authorization process.

The preceding functions have been provided as examples of the types of work performed by employees assigned in this job classification. Management reserves the right to add, modify, change or rescind work assignments and to make reasonable accommodations as needed. 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skills and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Requirements

Additional Responsibilities:

Communicate with Specialty Clinic Supervisor and nurses regarding any problem or questions with referrals.

Expectation of Service:  

This is a non-exempt 40 hour per week position. Regular and punctual attendance is required. Possible rotation of one weekend a month coverage.

Overtime may occasionally be required in order to complete assignments that are given by the Specialty Clinic Supervisor 

Physical Requirements:  

This position requires continual sitting and typing at a computer terminal, answering phone, some walking, twisting bending, stooping, and lifting of up to 25 pounds.  

Educations, Qualifications, Experience:

1. High School graduate or equivalent

2. Computer experience required

3. Medical Terminology preferred

4. Prefer previous experience in prior authorization, medical billing or insurance coordination.

5. Excellent organizational, communication, and problem-solving skills.

6. Ability to work independently and manage multiple authorizations efficiently.

Personal Characteristics:

Be able to communicate with customers and associates in a professional manner.

Knowledge, Skills, and Abilities:

1. Computer Experience

2. Typing

3. Telephone Etiquette

4. Communication Skills

5. Customer Service

5. Conflict Management with irate customers or insurance companies.

Equipment:

• Be able to use computer, calculator, copy machine, and fax machine.