Prior Authorization & Referral Specialist – Athenahealth

University Physicians' Association•Knoxville, TN

About The Position

University Center for Pain Management is seeking an experienced, detail-oriented Prior Authorization & Referral Specialist with strong working knowledge of Athenahealth and insurance authorization processes. The specialist coordinates and manages prior authorizations and referrals for diagnostic imaging, medications, procedures, and other medically necessary services. The role requires navigating Athenahealth, communicating with insurers and healthcare providers, and proactively following requests through approval or resolution. Experience in pain management, orthopedics, neurology, gastroenterology, or another specialty practice is preferred. This is a full-time position, Monday through Friday, 8:00 AM to 4:30 PM. Success in the role includes reducing authorization delays, maintaining organized tracking and consistent follow-up, submitting complete documentation, and communicating clearly with providers, staff, insurers, pharmacies, and imaging facilities to help prevent appointment cancellations and treatment delays.

Requirements

Previous experience in medical prior authorizations, referrals, or insurance authorization coordination.
Demonstrated working knowledge of Athenahealth.
Hands-on experience obtaining authorizations for diagnostic imaging and medications.
Familiarity with insurance portals, payer guidelines, and authorization tracking.
Strong organizational skills and the ability to manage multiple requests and deadlines.
Excellent written, verbal, and telephone communication skills.
Ability to work independently, troubleshoot problems, and follow requests through to completion.
Strong attention to detail and accurate documentation practices.

Nice To Haves

Experience in a specialty medical practice, preferably pain management; experience in orthopedics, neurology, gastroenterology, or another specialty practice is also noted as preferred.
Experience with MRI and CT authorizations, prescription medication prior authorizations, and procedure approvals.
Familiarity with pharmacy benefit managers and electronic medication authorization workflows.
Experience handling denials, appeals, and peer-to-peer review coordination.
Knowledge of Medicare Advantage, commercial insurance, and other payer requirements.
Experience managing high-volume authorization requests in a fast-paced medical office.

Responsibilities

Navigate Athenahealth to manage referrals, authorization requests, patient records, and documentation.
Enter, update, and track authorization and referral information in patient charts; monitor pending requests and maintain organized follow-up records.
Ensure documentation is complete and accessible to clinical and administrative staff, using Athenahealth work queues, tasks, and tracking tools.
Obtain prior authorizations for MRI, CT, X-ray, and other diagnostic imaging services as required by insurance plans.
Determine insurance-specific requirements, including referral, clinical documentation, and medical-necessity criteria; submit supporting documentation and follow up on pending requests.
Coordinate with imaging facilities and insurance companies to obtain authorization numbers and approval dates, resolve delays or denials, and communicate approval status and scheduling requirements.
Process medication prior authorizations through insurance portals, electronic systems, and telephone communication.
Understand and address formulary requirements, preferred medications, step therapy, quantity limits, and other coverage restrictions; coordinate with pharmacies, insurers, and clinical staff when additional information is needed.
Monitor medication authorization requests through determination, assist with appeals and reconsiderations for denials in coordination with the prescribing provider, and communicate outcomes and next steps to the clinical team.
Process specialist referrals and insurance-required authorizations; verify referral requirements and ensure necessary documentation is submitted.
Obtain authorizations for covered procedures and services as applicable, track expiration dates and approved service limits, and coordinate with referring providers, receiving facilities, and insurers to resolve issues.
Verify insurance eligibility and benefits relevant to referrals, imaging, medications, and procedures; identify payer-specific authorization requirements before scheduling when possible.
Contact commercial insurance plans, Medicare Advantage plans, and other payers as appropriate; maintain accurate logs of pending, approved, denied, and appealed requests.
Escalate complex denials or unresolved cases to the practice manager or clinical team and promptly communicate delays or authorization status changes.
Identify reasons for authorization denials and determine administrative steps for resolution; prepare and submit reconsiderations or appeals using documentation provided or approved by the clinical team.
Maintain complete, accurate, and timely records of authorization activities, protect confidential patient information, comply with HIPAA requirements and payer policies, and follow practice procedures without independently making clinical medical-necessity determinations.