Referral and Prior Authorization Specialist

Cone Health Medical Group; Greensboro (NC); Sur place; USD 42 000 - 62 000; Plein temps

Résumé du poste

Cone Health Medical Group in Greensboro, NC is seeking a Referral and Prior Authorization Specialist to coordinate referrals, verify insurance, and secure authorizations for medically necessary care. You will liaise with patients, providers, payers, and external organizations, maintain HIPAA-compliant records, and ensure timely documentation in the EHR while managing work queues and appeals.

Requires at least two years in a healthcare access role and a high school diploma; preferred CMA or

Qualifications

• Two years of healthcare experience in patient access, referrals, verification or revenue cycle.
• Experience with electronic medical records is preferred.
• Ability to interpret payer requirements and document outcomes clearly.

Responsabilités

• Initiate, review and process referrals to specialists, testing facilities, and community resources.
• Verify insurance eligibility and benefits using third-party portals and notify patients accordingly.
• Determine authorization requirements and submit complete requests with supporting documentation.
• Coordinate referral appointments with patients, payers, and providers and transmit required documents.
• Monitor work queues, follow up with insurers and providers, and document case status.
• Close referral loops by obtaining consultation reports and updating the EHR.
• Manage appeals and resolve denied or pending referrals and authorizations.
• Act as liaison between providers, insurers and patients for questions about referrals and authorizations.
• Maintain confidentiality and comply with HIPAA and state regulations.

Connaissances

Referral coordination

Insurance verification

Customer service

Payer liaison

HIPAA compliance

Formation

High School diploma or GED

Medical Assistant training / related healthcare education

Description du poste

The Referral and Prior Authorization Specialist coordinates referrals, prior authorizations, and related patient access activities. This position serves as a liaison between patients, providers, payers, and external healthcare organizations to ensure timely access to medically necessary care, accurate documentation, and compliance with payer requirements.

Essential Job Function

• Initiate, review and process incoming and outgoing referrals to specialists, ancillary providers, testing facilities, and community resources.
• Verify insurance eligibility and benefits of patient coverage by third party payers using appropriate eligibility websites to monitor and flag potential coverage issues to patients and providers.
• Determine authorization requirements based on payer guidelines and obtain required referrals, pre-certifications, and prior authorizations by preparing and submitting complete requests with supporting clinical documentation.
• Coordinate referral appointments and procedures in collaboration with patients, payers, and providers, ensuring all required referral and authorization documentation is transmitted to the appropriate internal and external entities.
• Monitor referral and authorization of work queues, follow up with insurers and providers, and maintain detailed documentation of communications and case status.
• Close referral loops by obtaining consultation reports and maintaining accurate, timely documentation within the electronic health record.
• Manage appeals and resolve denied, rejected, or pending referrals and authorization requests.
• Act as a liaison between providers, insurance representatives and patients to address questions and concerns related to referrals and prior authorizations.
• Maintain confidentiality and comply with HIPAA, state regulations, and internal policies

Education

Required: High School Diploma or GED

Preferred: Medical Assistant training, medical office certification, healthcare administration coursework, or related healthcare education

Experience

Required: Two years of experience in a healthcare setting with responsibilities related to patient access, referral coordination, insurance verification, authorizations, revenue cycle, or customer service.

Preferred: Experience working within electronic medical record workflows, referral work queues, and payer portals preferred.

Required

Licensure / Certification Experience

Preferred

• Certified Medical Assistant (CMA)
• Certified Medical Administrative Assistant (CMAA)
• Applicable healthcare administrative certification