Authorization Integrity Specialist - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health (US)•Pike, NY

1d•Onsite

About The Position

Responsible for proactive authorization controls that protect claim readiness and revenue prior to billing. Performs both pre-service authorization verification and post-procedure pre-bill validation to ensure the authorization aligns with services actually performed. Works high-risk scheduled and procedural accounts (for example OR, Cath Lab, IR, advanced imaging, and other prior-auth-dependent services) and coordinates timely corrections with Central Scheduling, clinical departments, physician offices, and revenue cycle teams. This role is part of Revenue Integrity and collaborates with Denials, CDI, UR, HIM, and Patient Access.

Requirements

High school diploma or equivalent.
Three years' hospital revenue cycle, prior authorization, patient access financial clearance, or related experience.
Experience working with payer portals and authorization documentation workflows required.
Strong competency in procedural authorization validation and post-procedure pre-bill authorization reconciliation
Strong knowledge of payer authorization requirements, including CPT/HCPCS, units, date range, site of service, and level of care dependencies.
Strong understanding of hospital claim flow and pre-bill controls.
Strong analytical and detail orientation with ability to identify mismatches quickly.
Effective communication skills for provider offices, clinical leaders, scheduling teams, and billing teams.
Strong organizational and follow-through skills in high-volume environments.
Proficiency with EHR/revenue cycle platforms, payer portals, and authorization tools.
Proficiency with Microsoft Excel and standard documentation/work queue tools.
Ability to function with minimal supervision and exercise sound judgment.
Ability to collect, create and research complex or diverse information.

Nice To Haves

Registered Nurse (RN) license preferred.
Certification or license in surgical or diagnostic procedures
Experience with procedural/surgical authorizations and account-level pre-bill review preferred.

Responsibilities

Performs pre-service authorization integrity review for scheduled high-risk accounts to confirm authorization is present, valid, and aligned with planned services.
Verifies authorization elements including payer, CPT/HCPCS, diagnosis linkage (as applicable), units, date span, rendering/facility, and site/setting (inpatient/outpatient/observation).
Performs post-procedure pre-bill authorization validation by comparing final services performed/coded to authorization approvals and identifies mismatches prior to claim release.
Identifies and resolves variances such as missing authorization, incorrect CPT, wrong units, wrong site/setting, expired authorization, and add-on procedure gaps.
Initiates timely correction workflows with Central Scheduling, physician offices, and clinical departments; escalates unresolved high-risk accounts.
Applies hold/release standards for accounts with unresolved authorization risk before billing finalization.
Documents findings, actions, contacts, and final disposition in designated work queues/trackers using standard issue categories and closure criteria.
Communicates clearly with downstream billing/follow-up teams regarding account status and required next steps.
Supports retro-authorization and post-service correction workflows where permitted; routes non-correctable cases to the appropriate Denials team pathway after pre-bill controls are exhausted.
Tracks recurring defects and contributes to root-cause trending (for example scheduling workflow gaps, provider office process issues, payer rule changes, documentation timing issues).
Participates in daily/weekly huddles with Revenue Integrity and cross-functional partners to improve first-pass claim quality.
Maintains productivity, quality, and turnaround standards established by Revenue Integrity leadership.
Assists with onboarding, cross-training, and workflow documentation updates as requested.
Performs other duties as assigned.