Referral / Authorization Specialist (Remote)-USA-Job-ID-1171

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Job Title: Referral / Authorization Specialist

Location:Must live in the Pacific Time Zone

Pay:$22.00-24.00 per hour

Work Arrangement:100% Remote

THIS POSITION REQUIRES EXPERIENCE IN HEALTHCARE Candidates must have 1+ years of managed care experience and/or medical office processing referrals / authorizations for medical services.

Experience Required:1+ Years of Relevant Experience (Healthcare Experience REQUIRED)

Company Overview:Our organization is committed to enhancing the healthcare journey for our members. We are dedicated to delivering accessible, high-quality care tailored to the unique needs of our communities. As a Referral / Authorization Specialist, you will play a crucial role in ensuring our members promptly receive the services they require.

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Summary:We are seeking a highly organized and detail-oriented individual to join our team. The ideal candidate will possess extensive knowledge of prior authorization and referrals processes, medical terminology, and ICD-10 coding. The primary responsibilities include processing faxes, building authorizations, and effectively communicating with healthcare providers. This role requires a strong understanding of medical billing codes, computer literacy, and the ability to ensure compliance with State and Federal healthcare regulations.

Essential Functions:

  • Provide accurate and efficient computer entries for authorization requests and provider inquiries through phone, mail, or fax.
  • Verify member eligibility and benefits to facilitate appropriate authorization procedures.
  • Determine provider contracting status and ensure appropriateness for the requested services.
  • Assess diagnosis and treatment requests, assigning appropriate billing codes (ICD-10 and/or CPT/HCPC codes).
  • Verify coordination of benefits (COB) status for members.
  • Verify and maintain inpatient hospital census, including admissions and discharges.
  • Coordinate with healthcare providers to ensure timely and accurate information exchange.
  • Communicate with healthcare providers, both verbally and in writing, to gather necessary information and address inquiries.
  • Triage members and information to the appropriate Health Care Services staff, ensuring seamless workflow.
  • Enter relevant data into systems accurately and promptly.
  • Maintain up-to-date and comprehensive records of authorizations and related information.
  • Check eligibility for members requiring hospitalization or utilization review for other healthcare services.
  • Verify and communicate benefits information to relevant stakeholders.

Qualifications:

  • Proficiency in medical terminology, ICD-10 coding, and prior authorization processes.
  • Strong computer literacy and experience with healthcare databases.
  • Excellent organizational and multitasking skills.
  • Effective communication skills, both written and verbal.
  • Detail-oriented with a commitment to accuracy.
  • Ability to work collaboratively in a team-oriented environment.

Education and Experience:

  • High school diploma or equivalent; Bachelor’s degree in a related field is a plus.
  • 1+ year of experience in referral and authorization coordination within the healthcare or managed care sector.
  • Familiarity with State and Federal healthcare regulations.

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