Preauthorization Specialist - Northeast Georgia Physicians Group NGPG - Orthopedics - FT Days

Northeast Georgia Health System•Braselton, GA

1d•Onsite

About The Position

The Preauthorization Specialist is responsible for securing timely and accurate insurance authorization and precertification for procedures, diagnostic tests, and other clinical services within a physician enterprise setting. This role ensures compliance with payer requirements, supports clinical operations, and helps optimize reimbursement by preventing claim denials related to authorization issues. The specialist works closely with providers, clinical staff, patients, and insurance companies to ensure all required documentation is obtained and processed efficiently.

Requirements

CPC Certification
High School Diploma or GED
3–5 years of relevant experience in insurance authorization, precertification, medical billing, revenue cycle, patient access, or related healthcare operations in a physician practice or medical group setting in lieu of CPC certification accepted.
Strong understanding of payer authorization requirements for procedures and diagnostic services.
Familiarity with commercial insurance, Medicare, Medicaid, managed care plans, and medical necessity guidelines.
Ability to read and understand clinical documentation.
Excellent communication and customer service skills.
Strong attention to detail, organization, and follow-through.
Proficiency with EHR systems, payer portals, and Microsoft Office applications.
Ability to work independently in a fast-paced physician enterprise environment.

Nice To Haves

CPB, CCA, CCS, or similar coding/billing credentials are beneficial and are strongly preferred.
Prior experience supporting specialties with complex authorization needs (e.g., cardiology, orthopedics, surgery, neurology, imaging).
Experience working in a multi-site physician enterprise or healthcare system setting.

Responsibilities

Verify whether procedures, imaging studies, surgeries, outpatient services, and specialty referrals require prior authorization based on payer rules.
Submit authorization requests through payer portals, phone outreach, or fax, ensuring accuracy and completeness of clinical information.
Obtain necessary medical records, clinical notes, and supporting documentation to submit with each authorization request.
Track authorization status and follow up with payers to avoid delays in patient care.
Document all authorization activities in the EHR and practice management systems accurately and in real time.
Review insurance benefits, eligibility, and coverage requirements for upcoming procedures.
Communicate authorization outcomes to scheduling teams, providers, and patients.
Identify and escalate issues involving coverage gaps, medical necessity denials, or incomplete clinical information.
Work closely with physicians, advanced practice providers, nurses, and scheduling staff to ensure all clinical data needed for authorization is available.
Notify departments of pending or unresolved authorizations that may impact scheduling or reimbursement.
Provide guidance to clinic teams on payer authorization requirements and documentation recommendations.
Maintain detailed, accurate authorization records that support audit readiness.
Ensure compliance with payer rules, regulatory requirements, and organizational policies.
Participate in process improvement activities to enhance authorization efficiency and accuracy.