CLINIC REFERRAL & PRIOR AUTHORIZATION



Summary

Responsible for the coordination and completion of assigned patient referrals and prior authorization requirements. Ensures referrals and authorizations are processed accurately and timely to support patient access to services, minimize delays in care, and reduce the risk of claim denials related to referral or authorization requirements.

Essential Duties and Responsibilities include the following:

• Reviews and processes referral and prior authorization requests received from clinic staff and other appropriate sources.
• Verifies patient insurance eligibility and benefits and determines referral and/or prior authorization requirements based on the patient's insurance plan and requested service.
• Accurately enters and maintains referral and prior authorization information in the appropriate practice management, electronic medical record, payer, and authorization systems.
• Obtains required referrals and prior authorizations from insurance companies, including submission of clinical documentation and other supporting information as required.
• Reviews payer requirements and ensures all required documentation is obtained and submitted with referral and authorization requests.
• Monitors pending referrals and prior authorization requests and follows up with insurance companies and other entities to obtain timely determinations.
• Tracks authorization status, authorization numbers, effective dates, expiration dates, approved services, units, visits, and other applicable limitations.
• Communicates referral and prior authorization status, including approvals, denials, requests for additional information, and other payer decisions to appropriate clinic staff.
• Identifies referrals and prior authorization requests that require additional information, physician review, peer-to-peer review, or other action and coordinates follow-up as needed.
• Works with insurance companies, physician offices, specialty providers, facilities, and clinic staff to resolve referral and authorization issues.
• Identifies potential authorization or referral issues that could result in delayed patient care or claim denials and takes appropriate action to resolve them prior to the scheduled service whenever possible.
• Maintains accurate and timely documentation of all referral and authorization activity, including payer communications, submission dates, follow-up activity, determinations, and other relevant information.
• Reviews and responds to tasks, messages, and work queues in the practice management and electronic medical record systems as needed.
• Performs follow-up on denied or incomplete authorization requests and assists with obtaining additional information or resubmitting requests when appropriate.
• Maintains knowledge of payer-specific referral and prior authorization requirements and communicates significant changes to appropriate staff.
• Protects patient confidentiality and follows all applicable organizational policies and procedures regarding patient information.
• Performs other related duties and responsibilities as assigned.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Problem Solving – Identifies and resolves problems in a timely manner and knows when to escalate issues requiring additional assistance.

Attention to Detail – Accurately reviews patient, insurance, referral, and authorization information and identifies discrepancies or missing information.

Planning/Organizing – Prioritizes and plans work activities, uses time efficiently, and manages multiple referrals and authorization requests while meeting required deadlines.

Communication – Communicates effectively with patients, clinic staff, providers, insurance companies, and outside organizations.

Teamwork – Balances team and individual responsibilities and works collaboratively with clinic and Business Office staff.

Quantity and Quality – Completes work in a timely manner while maintaining accuracy and quality.

Customer Service – Responds professionally and courteously to patients, clinic staff, providers, and payer representatives.

This position description is intended to provide an overview of the requirements of the position. As such, it is not necessarily all inclusive, and employees may be requested to perform job-related tasks other than those specifically outlined in the description. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.