Referral / Authorization Specialist

Job Title: Referral / Authorization Specialist

Location:
Must live in the Mountain Time Zone

Pay: $24.00 per hour and up

Work Arrangement: 100% Remote

Exp
erience Required: 1+ Years of Relevant Experience (Healthcare Experience REQUIRE
D)

Company Overview: Our organization is committed to enhancing the healthcare journey for our members. We are dedicated to delivering accessible, high-quality care tailored to the unique needs of our communities. As a Referral / Authorization Specialist, you will play a crucial role in ensuring our members promptly receive the services they require.

Summary: We are seeking a highly organized and detail-oriented individual to join our team. The ideal candidate will possess extensive knowledge of prior authorization and referrals processes, medical terminology, and ICD-10 coding. The primary responsibilities include processing faxes, building authorizations, and effectively communicating with healthcare providers. This role requires a strong understanding of medical billing codes, computer literacy, and the ability to ensure compliance with State and Federal healthcare regulations.

Essential Functions:

• Provide accurate and efficient computer entries for authorization requests and provider inquiries through phone, mail, or fax.
• Verify member eligibility and benefits to facilitate appropriate authorization procedures.
• Determine provider contracting status and ensure appropriateness for the requested services.
• Assess diagnosis and treatment requests, assigning appropriate billing codes (ICD-10 and/or CPT/HCPC codes).
• Verify coordination of benefits (COB) status for members.
• Verify and maintain inpatient hospital census, including admissions and discharges.
• Coordinate with healthcare providers to ensure timely and accurate information exchange.
• Communicate with healthcare providers, both verbally and in writing, to gather necessary information and address inquiries.
• Triage members and information to the appropriate Health Care Services staff, ensuring seamless workflow.
• Enter relevant data into systems accurately and promptly.
• Maintain up-to-date and comprehensive records of authorizations and related information.
• Check eligibility for members requiring hospitalization or utilization review for other healthcare services.
• Verify and communicate benefits information to relevant stakeholders.

Qualifications:

• Proficiency in medical terminology, ICD-10 coding, and prior authorization processes.
• Strong computer literacy and experience with healthcare databases.
• Excellent organizational and multitasking skills.
• Effective communication skills, both written and verbal.
• Detail-oriented with a commitment to accuracy.
• Ability to work collaboratively in a team-oriented environment.

Education and Experience:

• High school diploma or equivalent; Bachelor's degree in a related field is a plus.
• 1+ year of experience in referral and authorization coordination within the healthcare or managed care sector.
• Familiarity with State and Federal healthcare regulations.