Referral and Prior Authorization Specialist

Cone Health Medical Group; Greensboro (NC); On-site; USD 42,000 - 56,000; Full time

Job summary

Cone Health Medical Group seeks a Referral and Prior Authorization Specialist to coordinate referrals, pre-authorizations, and related patient access activities. You will serve as a liaison among patients, providers, payers, and external organizations to ensure timely access to care and accurate documentation.

The position requires at least two years in a healthcare setting focused on patient access, referral coordination, insurance verification, or revenue cycle.

Qualifications

• Requires high school diploma or GED.
• Two years of healthcare experience with patient access, referral coordination, insurance verification, or related responsibilities.
• Preferred CMA, CMAA, or applicable healthcare administrative certification.
• Experience with electronic medical records workflows is a plus.

Responsibilities

• Initiate, review and process referrals to specialists, ancillary providers, testing facilities, and community resources.
• Verify insurance eligibility and benefits using payer websites; flag potential coverage issues.
• Determine authorization requirements and obtain referrals, pre-certifications, and prior authorizations with supporting documentation.
• Coordinate referral appointments and documentation with patients, payers, and providers.
• Monitor referral and authorization queues; follow up with insurers and providers; document case status.
• Close referral loops by obtaining consultation reports and ensuring timely documentation in the EHR.
• Manage appeals and resolve denied or pending referrals and authorizations.
• Act as liaison between providers, insurance representatives and patients regarding referrals.
• Maintain confidentiality and comply with HIPAA and internal policies.

Education

High School Diploma or GED

Medical Assistant training

Medical office certification

Healthcare administration coursework

Related healthcare education

Job description

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.

Licensure / Certification Experience

Required:

Preferred:

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