Summary of Position:

The Referral and Prior Authorization Specialist is responsible for obtaining referrals and authorizations to ensure reimbursement for services and testing provided throughout Saratoga Hospital Medical Group (SHMG). Demonstrates excellent communication, strong customer service, critical thinking, and problem solving skills. Completes all appropriate forms, applications, and necessary information. Accurately manages the referral and authorization process. Able to secure authorization and necessary documentation to ensure patient care is not impacted and meets time-sensitive requests. Is pro-active in troubleshooting instances which could result in great financial loss. Demonstrates excellent customer service skills and works in a positive manner for collaboration and clear communication between providers, staff, insurers, and families. The specialist works closely with the appropriate clinical team members for information gathering and patient data. Meets turnaround expectations for majority of prior authorization approvals.

Primary Job Responsibilities:

Processes all referrals and authorizations received. Completes prior authorizations and referrals as required for services and testing. Collaborates with clinical team members, physician offices and agencies to ensure than an accurate and timely referral/authorization is processed and documented in accordance with department guidelines.

Manages and maintains the Electronic Referral Tracking Report for accuracy of information, urgency, and other designated criteria.

Acts as a resource to all internal and external customers, offering guidance and support for referral and authorization related questions and referral/authorization processing problems. Ensures patients receive timely and courteous communications.

Informs referring providers when a requested service authorization request is denied.

Stays current with the insurance authorization requirements by utilizing the resource library of payor benefit-specific information and provider contact information.

Enters referrals and authorizations in to the system per standardized practice protocols and provides feedback to ordering provider and parent/patient in a timely manner.

Documents and provides updates in the patient's medical record, the status of the referral and/or authorization.

Communicates and provides feedback to providers and staff regarding changes, trends, and processes.

Minimum Qualifications: High school graduate or GED. At least two years in a medical office or insurance company environment, experience with prior authorizations and referrals required. Medical terminology certificate preferred.