Referral and Authorization Specialist

Care New England Health System•Warwick, RI

About The Position

The Referral and Authorization Specialist supports the organization’s financial health and patient experience by managing referrals and authorizations for specialty visits and outpatient testing. The role centralizes and streamlines authorization workflows, obtains timely and accurate authorization information before services are performed, helps reduce claim denials, and supports payer compliance and reimbursement. The Specialist requests, tracks, verifies, and documents insurance referrals and prior authorizations using the organization’s EHR, while coordinating with payer representatives, third-party authorization companies, internal departments, and external referring providers. The position also manages the start of the external referral process for CNEMG primary care providers, including submitting referrals, obtaining authorization, and forwarding relevant clinical documentation. It includes explaining specified waiver notices to patients and monitoring EHR work queues and inbox pools throughout the workday.

Requirements

High school diploma or GED required.
Five to seven years of experience working in healthcare.
Three years of experience processing insurance referrals and/or prior authorizations.
Ability to communicate sensitively and compassionately with people from diverse backgrounds.
Knowledge of federal regulations related to the No Surprises Act and healthcare billing compliance.
Excellent presentation, communication, organizational, and customer service skills.
Strong understanding of payer requirements, authorization processes, insurance, and medical terminology.
Specialized knowledge and thorough understanding of Microsoft 365, EHRs (specifically EPIC), and HIPAA.
Prioritizes patients’ needs and ensures quality and safety requirements are met.
Strong listening, written and verbal communication, and interpersonal skills for interacting positively with patients and staff at all organizational levels.
Strong critical-thinking skills and ability to troubleshoot and resolve issues.

Nice To Haves

Associate degree or Certified/Registered Medical Assistant credential.
Bilingual ability.

Responsibilities

Request and obtain insurance referrals and prior authorizations through insurance carriers and third-party authorization companies, and track their status in CNE’s EHR.
Evaluate payer policies concerning authorization and notice of admission requirements.
Communicate referral and prior authorization requests and status to internal referring provider offices and departments through the EHR.
Document work related to obtaining or verifying insurance referrals and prior authorizations in CNE’s EHR.
Coordinate with internal and external referring provider offices and departments to obtain information needed to secure or verify approvals.
Verify patient insurance information for referral and prior authorization processing.
Notify referring departments through the EHR of processing issues, including outdated PCP information with the payer, incomplete provider documentation, or inaccurate insurance information.
Escalate issues involving the approval of referrals and prior authorizations to management.
Manage the start of the external referral process for all CNEMG PCPs, including submitting referrals, obtaining approved insurance authorization, and sending relevant clinical documentation to external providers.
Explain the Notice of Non-Covered Service Waiver and Notice of Non-Approved Prior Authorization waiver to patients.
Work and monitor EHR work queues and In Basket pools throughout the workday.
Perform other duties as assigned.