Referral Authorization Specialist

Our Mission

All of us, for each of you, every time.

Our Vision

Together, serving as the trusted regional healthcare partner.

Our Values

Listen~Love~Respect~Excel~Innovate

ESSENTIAL FUNCTIONS

Prior Authorization Management

1. Obtain prior authorizations for hospital and clinic services, including but not limited to, outpatient procedures, imaging, surgeries, and other specialty services.
2. Identify the health plan(s) by confirming information provided and verifying eligibility and coverage.
3. Verify payer requirements for authorization, referral, and medical necessity requirements based on plan guidelines.
4. Submit complete and accurate authorization requests with appropriate clinical documentation.
5. Track authorization status and follow up with the payer at regular intervals to ensure timely approvals.
6. Escalate urgent or complex cases to avoid delays in patient care.
7. Document authorization numbers, effective dates, and limitations in the EMR.
8. Communicate authorization delays and denials to ordering providers and clinics.
9. Monitor authorization workqueues and ensure timely completion.

Referral Management

1. Coordinate with providers and clinics to ensure appropriate scheduling and continuity of care.
2. Process outgoing referrals for specialty care.
3. Ensure referrals meet payer and regulatory requirements (e.g., PCP referrals, network rules).
4. Monitor referral workqueues and ensure timely completion.

Denial Prevention & Revenue Cycle Support

1. Review payer policies to ensure compliance and minimize denials.
2. Partner with coding, billing, and clinical teams to resolve authorization-related denials.
3. Inform department professionals and/or providers when peer-to-peer review is necessary. Assist as needed.
4. Assist with retro authorization requests and appeals as needed.
5. Identify trends and recommend process improvements.

Communication & Assistance

1. Serve as the point of contact for patients regarding referral and authorization status.
2. Communicate clearly with providers, clinical staff, payers, and patients.
3. Educate patients on authorization and referral procedures and next steps.
4. Maintain ongoing tracking and documentation for prior authorizations and referrals to promote team awareness.
5. Ensure HIPAA compliance when sharing patient information with authorized care providers.

General

1. Participate in continuing education opportunities.
2. Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest trends in the field of expertise.
3. Ensures no injuries to self or others by following safe work practices and policies. This includes, but is not limited to: security and safety, understanding of chemical Safety Data Sheets (SDS), equipment, infection control, fire, disaster, safe lifting and body mechanics.
4. Ensures self-compliance with organization policies and procedures, as well as labor agreements.
5. Ensures the interface with team members and other support groups is conducted in a courteous and efficient manner conducive to the organization's values.
6. Conducts self in a professional manner and ensures personal appearance meets the standards necessary to perform the job function while representing the organization.
7. Ensures that additional accountabilities, as may be required by management, be handled in a manner necessary to meet organizational standards.

WORK ENVIRONMENT

The professional in this position reports to the Director of Revenue Cycle. Professionals in this position will work closely with patients and other Samaritan professionals within various departments.

EDUCATION & EXPERIENCE

• Education:
  1. High school diploma or equivalent required; Associate degree preferred.
• Experience:
  1. Minimum of two (2) years of experience in healthcare referrals, prior authorizations, or revenue cycle required.
  2. Experience working in a healthcare setting providing multi-specialty support preferred.
  3. Certified Healthcare Access Associate (CHAA) or similar certification preferred.
  4. Experience with Medicare, Medicaid (including Washington Apple Health), and commercial payers.
  5. Understanding of medical necessity criteria and utilization management.
• Skills/Competencies:
  1. Strong knowledge of insurance plans, payer requirements, and authorization requirements.
  2. Familiarity with CPT, IDC-10, and medical terminology.
  3. Experience with EMR systems (EPIC) and payer portals (e.g., Availity, OneHealthPort, payer websites)
  4. Excellent organizational and time management skills.
  5. Ability to manage high-volume workqueues with attention to detail.
  6. Effective communication and interpersonal skills.
  7. Demonstrates competency on equipment listed on department specific checklist.
  8. Strong critical thinking skills: seeks resources for direction, when necessary. Performs independent problem solving. Decision-making is logical and deliberate.
  9. Performs actions that demonstrate accountability. Exercises safe judgment in decision-making. Practices within legal and ethical guidelines.
  10. Demonstrates competency in ability to care for customers/patients across the age continuum.

PHYSICAL REQUIREMENTS

1. Occasional lifting, reaching, kneeling, bending, stooping, pushing and pulling.
2. Occasional heavy lifting (lift/carry up to 50 lbs.).
3. Manual dexterity and mobility.
4. Ability to read and understand patient charts, provider orders, tests results, etc.
5. Ability to communicate using verbal and/or written skills for accurate exchange of information with physicians, nurses, health care professionals, patients and/or family, and the public.

As a Samaritan professional, you will be asked to carry out the Mission, Vision, Values, and Strategy of Samaritan, personifying service and operational excellence including the creation and maintenance of the best patient, professional, physician, and student experience.

Originally posted on Himalayas