Physician Authorization/Referral Specialist I

Nemours Children's Health; Wilmington (DE); On-site; USD 42,000 - 60,000; Full time

Job summary

Nemours Childrenb4s Health is seeking a Physician Authorization/Referral Specialist in the tristate area to ensure timely, coordinated care for patients.

The role involves verifying eligibility, communicating estimated patient costs, and obtaining referrals across specialties; collaborate with insurers, hospitals, and internal teams to maintain accurate records and support Medicaid enrollment while delivering excellent service.

Qualifications

• Minimum 1 year of referral/authorization work experience.
• Residence in PA, NJ, MD or DE as required.
• High School diploma required.

Responsibilities

• Obtain and process referrals and authorizations for outpatient services.
• Verify insurance eligibility, benefits, and patient cost estimates.
• Ensure copay requirements and payer approvals before services.
• Collaborate with insurers, providers, and internal teams to support communication.
• Maintain documentation in standard formats and support Medicaid enrollment where needed.
• Deliver empathetic customer service and comply with HIPAA and EMTALA.

Skills

Attention to detail

Customer service

Healthcare administration

Education

High School diploma

Tools

EPIC

Job description

Job Description

Join our team as a Physician Authorization/Referral Specialist, where you'll play a vital role in ensuring patients receive timely, coordinated care.

Applicants must reside in the tristate area: Pennsylvania, New Jersey, Maryland or Delaware.

The Specialist is responsible for obtaining and processing elective, urgent, and emergent referrals and authorizations for a wide range of outpatient services, including cardiology, audiology, lab testing, genetic testing, and certain medications. They verify insurance eligibility and benefits, calculate and communicate patient cost estimates, and ensure copay requirements and approvals are completed before services occur.

This role works closely with insurance companies, primary care providers, partner hospitals, and internal departments to ensure accurate information, timely claim processing, and seamless patient support. The Specialist uses daily reports and work queues to follow up on pending cases, participates in department huddles, and helps resolve issues that could affect reimbursement. They are also expected to deliver excellent customer service, support Medicaid enrollment processes, use EPIC effectively, and assist with training new team members.

Responsibilities

• Ensure timely notification and request for authorization/referrals is handled in accordance with departmental policy and payor requirements.
• Maintaining confidentiality, verify patient demographics, insurance eligibility, benefits, and financial responsibility.
• Ability of request/obtain authorizations/referrals for assigned specialties and be able to cover for most specialties.
• Communicate effectively, timely and professionally in writing and verbally
• Contact and interview families in person or by phone contact to obtain necessary information and assist them with insurance issues that may be preventing authorization/referrals.
• Clearly document all communications and contacts with payors and families in standardized documentation requirements including proper format
• Consistently demonstrates excellent, empathetic and knowledgeable customer service skills to internal and external customers
• Is aware and adheres to all State and Federal Regulations including, but not limited to: EMTALA, HIPAA, and the Joint Commission
• Ability to review workflows and suggest improvements in specialty areas
• Ability to work independently, prioritize workload and assist other associates as required.
• Build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
• Prepare estimates for scheduled services. Must interpret patient's benefits correctly for accurate estimates.
• Work with partner hospitals for claim submission and registration accuracy.

Qualifications

• Referral/authorization work experience required (minimum one year experience)
• High School diploma required
• Required to reside: Pennsylvania, Maryland, New Jersey or Delaware.

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Learn more at Nemours.org.