PRIOR AUTHORIZATION AND REFERRAL SPECIALIST

University of Texas - Rio Grande Valley; Edinburg (TX); On-site; USD 42,000 - 52,000; Full time

Job summary

University of Texas Rio Grande Valley seeks a Prior Authorization and Referral Specialist to manage authorizations and referrals, verify patient benefits, and document details in the EMR for claims processing. The role supports the School of Medicine/ Revenue Cycle and requires strong computer skills.

You will coordinate with health plans, providers, and patients to ensure timely approvals, educate patients on coverage limitations, and maintain accurate records.

Qualifications

• One year of experience processing prior authorizations and referrals in a medical setting.
• Knowledge of interpreting commercial insurance coverages to include Medicaid and Medicare.

Responsibilities

• Processes prior authorizations and referral requests in a timely manner, prior to the patients' services being rendered.
• Verifies member eligibility and benefits via health plan portals or eligibility services and enters information into the EMR for authorization tracking.
• Notifies parties within required timeframes for routine and urgent requests for services.
• Communicates with providers, physicians, and staff to obtain documentation, CPT/diagnosis codes for authorizations or referrals.
• Communicates with patients to educate them on limitations or additional services that may require carrier contact.

Skills

Bilingual (Spanish)

Exceptional computer skills

Strong organizational skills

Independent worker

Education

High School diploma/GED

Tools

EMR

Microsoft Office

Job description

PRIOR AUTHORIZATION AND REFERRAL SPECIALIST

Posting Number: SRGV9089

Number of Vacancies: 1

Location: Edinburg, Texas

Department: School of Medicine/ Revenue Cycle

FLSA: Non-Exempt

Scope of Job: Responsible for obtaining and processing all prior authorizations and referrals and entering the completed referral into the electronic medical record system for claims adjudication to ensure services are validated.

Description of Duties:

• Processes prior authorizations and referral requests in a timely manner, prior to the patients' services being rendered.
• Responsible for researching patient member benefits, additional coverages, coverage limitations, and general coverage allowances to obtain the necessary authorizations and referrals for patient services.
• Obtains and receives referral requests from providers and health plans related to services for patient visits and procedures.
• Verifies member eligibility and benefits via the health plan provider online portals or health plan provider eligibility services via fax or phone and enters the information into the EMR system accurately for authorization tracking.
• Notifies the necessary parties within the required timeframe for routine and urgent requests for services.
• Communicates with patients to effectively educate them on any limitations or additional services that may require contact with their insurance carrier to ensure coverage.
• Communicates with providers, physicians, and other medical personnel regarding necessary documentation, CPT codes, diagnosis codes, or other information required to obtain the necessary authorizations or referrals.
• Communicates with patient service representatives to obtain or correct patient demographics as needed.
• Communicates authorization information and coverage to appropriate departmental staff in a timely manner.
• Communicates effectively with health plans, payor representatives, and network and claims department staff to resolve complex authorization issues.
• Coordinates with health plans and payor representatives for outpatient, inpatient, DME discharge planners, home health providers, and other services as needed when applicable.
• Is a source of knowledge for primary care providers regarding specialist referrals.
• Performs other duties as assigned.

Supervision Received: General supervision from assigned supervisor.

Supervision Given: Direct supervision of assigned staff.

Required Education: High School diploma/GED.

Preferred Education: None

Licenses/Certifications: None

Required Experience: One (1) year of experience processing prior authorizations and referrals in a medical setting. Knowledge of interpreting commercial insurance coverages to include: Medicaid and Medicare.

Preferred Experience: Bilingual, Spanish speaking preferred.

Equipment: Use of standard office equipment including knowledge of Microsoft Office and previous use of EMR (Electronic medical record systems).

Working Conditions: Needs to be able to successfully perform all required duties. Office/Clinic Environment; some travel and weekend work is required. Exerting up to 10 pounds of force occasionally, and/or an negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. UTRGV is a distributed institution, which requires presence at multiple locations throughout the Rio Grande Valley.

Other: Exceptional computer skills and experience are required. The ability to work independently with minimal supervision and strong organizational skills with attention to detail is necessary to ensure efficient and quality operations. Ability to interpret medical insurance coverages. Strong knowledge of insurance terminology.

Physical Capabilities: None.

Employment Category: Full-Time

Minimum Salary: Commensurate with Experience

Posted Salary: Commensurate with Experience

Position Available Date: 08/17/2026

Grant Funded Position: No

EEO Statement: It is the policy of The University of Texas Rio Grande Valley to promote and ensure equal employment opportunities for all individuals without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or protected veteran status. In accordance with the requirements of Title VII of the Civil Rights Act of 1964, the Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, as amended, our University is committed to comply with all government requirements and ensures non-discrimination in its education programs and activities, including employment. We encourage women, minorities and differently abled persons to apply for employment positions of interest.

Special Instructions to Applicants: Dear Applicant, Human Resources will not be held responsible for redacting any confidential information from the documents you attach with your application. The confidential information includes the following: Date of Birth, Social Security Number, Gender, Ethnicity/Race. Please make sure that you omit this information prior to submission. We are advising that Human Resources will be forwarding your application to the department as per your submission. If you have any questions, please do not hesitate to contact us at [phone] and/or [e-mail].

Additional Information: UTRGV is a distributed location institution and working location is subject to change based on need.

All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.

Substitutions to the above requirements must have prior approval from the VP of HR & Regulatory Affairs.