Referral & Authorization Specialist

Care New England; Warwick, Northern (RI, KY); On-site; USD 42,000 - 70,000; Full time

Job summary

Care New England in Warwick, RI seeks a Referral and Authorization Specialist to oversee referrals and prior authorizations for specialty visits and outpatient testing. You will centralize workflows, verify insurance details, and coordinate with internal and external offices to minimize claim denials and ensure payer compliance.

The role supports timely patient care and optimized reimbursement by handling authorization requests, tracking statuses in the EHR, and communicating issues to

Qualifications

• 5-7 years of experience in healthcare.
• 3 years of experience processing insurance referrals and prior authorizations.
• Bilingual preferred.
• Knowledge of No Surprises Act and billing compliance.
• Excellent communication and organizational skills.

Responsibilities

• Request and obtain insurance referrals and prior authorizations; track status in the EHR.
• Evaluate payer policies for authorization requirements.
• Communicate request/status with internal offices via the EHR.
• Document all referral/authorization activities in the EHR.
• Coordinate information with internal/external offices for approvals.
• Verify patient insurance information for referrals/authorizations.
• Flag issues in the EHR and communicate them to the referring department.
• Escalate authorization issues to management.
• Manage external referral process for CNEMG PCPs and share docs.
• Explain non-covered service waivers and non-approved authorization waivers to patients.
• Monitor EHR queues and in-basket work items; perform other duties.

Skills

Healthcare billing terminology

EHR EPIC knowledge

Communication with diverse patients

Payer policy understanding

Education

High School diploma; CMA preferred

Tools

EPIC EHR

Microsoft 365

Job description

Job Summary

The Referral and Authorization Specialist plays a vital and strategic role in supporting the financial health of the organization by overseeing the referral and authorizations processes for specialty visits and outpatient testing. This position is essential in centralizing and streamlining the authorization workflow, which is integral to the success of the organization’s operations, patient experience, and financial performance. Obtaining timely and accurate authorization information, prior to performing services, reduces claim denials, ensures payer compliance, and establishes better organizational financial outcomes. This position is crucial to the organization's financial success and the delivery of a positive provider and patient experience, as their timely and accurate processing of referrals and authorizations ensures that patients receive the necessary care without delays, while also optimizing reimbursement.

Duties & Responsibilities

1. Request and obtain insurance referral and prior authorizations via the insurance carrier and/or third-party authorization companies and then track the status within CNE’s EHR.
2. Evaluate payer policies to understand authorization and notice of admission policies.
3. Communicate the request/status of the insurance referral and/or prior authorization with internal referring provider offices/departments via the EHR.
4. Utilize CNE’s EHR to document all work related to obtaining and/or verifying insurance referral and prior authorizations.
5. Work with both internal and external referring provider offices/departments to obtain the necessary information to obtain and/or verify the approval of the insurance referral or prior authorization.
6. Verify the accuracy of the patient’s insurance information to obtain the insurance referral or prior authorization.
7. Communicate via the EHR any issues related to processing the referral (i.e., PCP not updated with the payer, provider documentation not complete) and/or the accuracy of the patient’s insurance information to the referring department.
8. Communicate any issues related to obtaining and/or verifying the approval of the insurance referral and/or prior authorization to management.
9. Manage the start of the external referral process for all CNEMG PCPs, to include submitting referrals, obtaining an approved insurance authorization, and sending all relevant clinical documentation to the external provider.
10. Explain the Notice of Non-Covered Service Waiver and Notice of Non-Approved Prior Authorization waiver to patients.
11. Work and monitor EHR WQ’s and in Basket pools through the workday.
12. Performs other duties as assigned.

Requirements

Education & Experience

High School or GED is required. Associate degree or Certified/Registered Medical Assistance preferred. 5-7 years of experience working in healthcare. 3 years of experience processing insurance referral and/or prior authorizations. Bilingual preferred.

Knowledge, Skills, & Abilities

• Ability to communicate with people of various diverse backgrounds in a sensitive and compassionate way.
• Knowledge of federal regulations related to the No Surprises Act and healthcare billing compliance.
• Must have excellent presentation, communication, organizational and customer service skills.
• Strong understanding of payer requirements, authorization processes, insurance and medical terminology.
• Possesses specialized level of knowledge and thorough understanding of the systems/applications and subjects listed below:
  • Microsoft 365 (formerly Microsoft Office)
  • EHRs, specifically EPIC, and
  • HIPAA
• Always puts patients’ needs first and ensures that quality and safety requirements are met.
• Possesses strong listening, communication (written and verbal) and people skills to positively interact with patients, and staff at all levels of the organization.
• Strong critical thinking skills with the ability to troubleshoot and resolve issues

About Us

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.

EEO Statements

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.