CLINIC REFERRAL & PRIOR AUTHORIZATION

Outsource Accelerator; Pasig; On-site; PHP 360,000 - 540,000; Full time

Job summary

Outsource Accelerator in Pasig, Philippines, is looking for a Clinic Referral & Prior Authorization coordinator to manage the coordination and completion of patient referrals and authorization requirements, ensuring accuracy and timeliness to support access and minimize delays.

You will verify insurance eligibility, enter data in EMR and payer systems, obtain authorizations, monitor status, and communicate decisions to clinic staff, with a strong focus on accuracy, attention to detail, and

Qualifications

• Strong problem-solving and analytical skills.
• Meticulous attention to detail in reviewing referrals and authorizations.
• Ability to plan, organize, and prioritize multiple requests.
• Effective communication with patients, clinics, and payers.

Responsibilities

• Reviews and processes referral and prior authorization requests.
• Verifies patient insurance eligibility and determines requirements.
• Enters and maintains referral and authorization data in systems.
• Obtains referrals and authorizations from insurers with required docs.
• Monitors and follows up on pending referrals and determinations.
• Communicates status and payer decisions to clinic staff.
• Identifies information gaps and coordinates follow-up actions.
• Maintains accurate documentation of all activity.

Skills

Problem solving

Attention to detail

Planning/organizing

Communication

Teamwork

Quantity and quality

Customer service

Job description

About the job CLINIC REFERRAL & PRIOR AUTHORIZATION

Summary

Responsible for the coordination and completion of assigned patient referrals and prior authorization requirements. Ensures referrals and authorizations are processed accurately and timely to support patient access to services, minimize delays in care, and reduce the risk of claim denials related to referral or authorization requirements.

Essential Duties and Responsibilities include the following:

• Reviews and processes referral and prior authorization requests received from clinic staff and other appropriate sources.
• Verifies patient insurance eligibility and benefits and determines referral and/or prior authorization requirements based on the patient's insurance plan and requested service.
• Accurately enters and maintains referral and prior authorization information in the appropriate practice management, electronic medical record, payer, and authorization systems.
• Obtains required referrals and prior authorizations from insurance companies, including submission of clinical documentation and other supporting information as required.
• Reviews payer requirements and ensures all required documentation is obtained and submitted with referral and authorization requests.
• Monitors pending referrals and prior authorization requests and follows up with insurance companies and other entities to obtain timely determinations.
• Tracks authorization status, authorization numbers, effective dates, expiration dates, approved services, units, visits, and other applicable limitations.
• Communicates referral and prior authorization status, including approvals, denials, requests for additional information, and other payer decisions to appropriate clinic staff.
• Identifies referrals and prior authorization requests that require additional information, physician review, peer-to-peer review, or other action and coordinates follow-up as needed.
• Works with insurance companies, physician offices, specialty providers, facilities, and clinic staff to resolve referral and authorization issues.
• Identifies potential authorization or referral issues that could result in delayed patient care or claim denials and takes appropriate action to resolve them prior to the scheduled service whenever possible.
• Maintains accurate and timely documentation of all referral and authorization activity, including payer communications, submission dates, follow-up activity, determinations, and other relevant information.
• Reviews and responds to tasks, messages, and work queues in the practice management and electronic medical record systems as needed.
• Performs follow-up on denied or incomplete authorization requests and assists with obtaining additional information or resubmitting requests when appropriate.
• Maintains knowledge of payer-specific referral and prior authorization requirements and communicates significant changes to appropriate staff.
• Protects patient confidentiality and follows all applicable organizational policies and procedures regarding patient information.
• Performs other related duties and responsibilities as assigned.

To perform the job successfully, an individual should demonstrate the following competencies:

Problem Solving – Identifies and resolves problems in a timely manner and knows when to escalate issues requiring additional assistance.

Attention to Detail – Accurately reviews patient, insurance, referral, and authorization information and identifies discrepancies or missing information.

Planning/Organizing – Prioritizes and plans work activities, uses time efficiently, and manages multiple referrals and authorization requests while meeting required deadlines.

Communication – Communicates effectively with patients, clinic staff, providers, insurance companies, and outside organizations.

Teamwork – Balances team and individual responsibilities and works collaboratively with clinic and Business Office staff.

Quantity and Quality – Completes work in a timely manner while maintaining accuracy and quality.

Customer Service – Responds professionally and courteously to patients, clinic staff, providers, and payer representatives.

This position description is intended to provide an overview of the requirements of the position. As such, it is not necessarily all inclusive, and employees may be requested to perform job-related tasks other than those specifically outlined in the description. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.