Precertification Specialist

The Precertification and Referral Coordinator is responsible for obtaining insurance authorizations, processing referrals, and verifying referral and precertification requirements for patient services. This position ensures that referrals, diagnostic testing, procedures, and specialist visits meet insurance requirements to support timely patient care and accurate reimbursement.

Essential Duties and Responsibilities

· Obtain prior authorizations and pre-certifications for procedures, diagnostic testing, medications, imaging, and other services as required by insurance carriers.

· Verify patient insurance coverage and determine authorization requirements before scheduled services.

· Submit authorization requests through insurance portals, electronic systems, fax, or telephone.

· Track pending authorizations and follow up with insurance companies to obtain timely decisions.

· Communicate authorization approvals, denials, and additional documentation requests to providers and appropriate staff.

· Maintain accurate records of authorization numbers, approval dates, expiration dates, approved services, and visit limits.

· Coordinate peer-to-peer reviews and assist with appeals or additional clinical documentation when necessary.

· Notify the appropriate staff of denied, delayed, or incomplete authorizations that may affect scheduled appointments or procedures.

· Create and communicate financial contracts for patients' office and hospital surgeries.

Referrals

· Process incoming and outgoing referrals for specialist consultations, testing, and other medical services.

· Verify whether insurance plans require primary care provider referrals, specialist referrals, or other approvals.

· Obtain and confirm referral authorization numbers, effective dates, expiration dates, and visit allowances.

· Authorizations of IUDs and contact the patient with appropriate information

· Enter referral information into the electronic health record (EHR), including eClinicalWorks, as applicable.

· Ensure referral documentation includes the necessary patient demographics, insurance information, diagnosis, provider details, and contact information.

· Send referrals and supporting clinical documentation to the appropriate specialists or facilities.

· Monitor referral status and follow up with insurance companies, referring providers, and specialist offices as needed.

· Communicate referral requirements and outstanding issues to patients and clinical staff.

· Maintain referral logs and ensure referrals are processed and documented accurately.

Insurance and Administrative Responsibilities

· Maintain current knowledge of insurance referral and authorization requirements for commercial plans, and Medicare.

· Use payer portals and electronic systems to check authorization and referral status.

· Communicate professionally with insurance representatives, patients, providers, and outside medical offices.

· Protect patient confidentiality and comply with HIPAA requirements.

· Maintain organized documentation and meet established turnaround times.

· Assist with other administrative duties as assigned by the Office Manager or Practice Administrator.

Qualifications

· Previous experience in medical office administration, referrals, precertification, prior authorizations, or insurance verification preferred.

· Knowledge of medical terminology, insurance benefits, and payer authorization requirements.

· Familiarity with CPT and ICD-10 codes preferred.

· Experience with eClinicalWorks or another electronic health record system preferred.

· Proficiency with insurance portals, Microsoft Office, fax systems, and electronic communication.

· Strong organizational, communication, and follow-up skills.

· Ability to manage multiple requests, prioritize deadlines, and work independently.

· Attention to detail and commitment to patient confidentiality.

Performance Expectations

· Process referrals and authorization requests accurately and within established timeframes.

· Follow up consistently on pending requests.

· Maintain complete and accurate documentation in the electronic health record.

· Identify potential authorization or referral issues before scheduled services whenever possible.

· Communicate delays, denials, and missing information promptly.

· Minimize preventable scheduling delays and claim denials related to missing referrals or authorizations.

Pay: $23.00 - $26.00 per hour

Expected hours: 40.0 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person