Referral/Authorization Specialist

South Florida Orthopaedics & Sports Medicine PA•Stuart, FL

About The Position

The Referral & Authorization Specialist is responsible for securing insurance referrals and prior authorizations for both internal and external patient services ordered or provided by the practice. This role ensures payer requirements are met prior to service delivery, supports accurate scheduling and financial clearance, and serves as a key liaison between patients, providers, payers, and outside facilities. Reviews and responds to NextGen tasks for diagnostic testing and referrals, including but not limited to EMG, venous Doppler, CT scans, bone scans, and external specialty consults. Accurately identifies payer requirements for authorizations and referrals and prioritizes STAT orders appropriately. Monitors upcoming appointment schedules to ensure required authorizations and referrals are obtained prior to patient visits. Proactively identifies authorization gaps and escalates time-sensitive cases as needed. Verifies patient insurance benefits and authorization requirements. Enters or verifies patient financial responsibility in Clearwave for check-in, or contacts patients directly to review and collect applicable balance. Submits authorization requests to third-party payers in accordance with plan requirements. Coordinates with PCP offices, patients, and internal clinical teams to obtain necessary referrals and supporting documentation. Tracks and follows up on pending authorizations within established timelines. Submits additional clinical documentation and medical records to payers as requested. Facilitates peer-to-peer reviews between providers and payers when require Schedules outside diagnostic testing when applicable and provides patients with accurate appointment details. Transmits referral authorizations and supporting office notes to external providers in a timely manner. Communicates authorization status clearly with patients, including approvals, delays, and denials. Notifies patients in advance when authorization has not been obtained and assists with rescheduling as appropriate. Accurately documents all authorization and referral activity in the patient’s NextGen medical record. Ensures data integrity across systems and proper use of required fields. Schedules follow-up appointments with the ordering provider after external diagnostic testing is completed. Confirms patients receive clear instructions regarding next steps in care. Provides cross-coverage within the Authorization team. Assistswith insurance verification and surgical authorizations as needed. Maintains strong working knowledge of payer plans, referral and authorization requirements, benefit structures, and electronic submission processes. Serves as a resource to staff and providers regarding authorization and documentation requirements. Identifies opportunities to improve efficiency and compliance in authorization workflows. Responds promptly and accurately to internal and external inquiries. Escalates complex or recurring issues to management and contributes to process improvement efforts. Represents the practice professionally in all interactions with patients, providers, payers, and external partners. Demonstrates working knowledge of NextGen, Luma, Clearwave, and related platforms. Understands system integrations and accurately captures required data for authorization tracking and reporting. Performs other related duties as assigned to support department operations.

Requirements

Strong knowledge of insurance referral and prior authorization processes
High attention to detail and accuracy
Ability to manage multiple priorities in a fast-paced clinical environment
Excellent verbal and written communication skills
Patient-focused, service-oriented approach
Strong organizational and follow-up skills
Electronic Health Records (NextGen preferred)
Practice management and patient engagement tools (e.g., Clearwave, Luma)
Insurance portals and payer authorization platforms
Microsoft Office and web-based systems

Responsibilities

Securing insurance referrals and prior authorizations for both internal and external patient services
Ensuring payer requirements are met prior to service delivery
Supporting accurate scheduling and financial clearance
Serving as a key liaison between patients, providers, payers, and outside facilities
Reviewing and responding to NextGen tasks for diagnostic testing and referrals
Accurately identifying payer requirements for authorizations and referrals and prioritizes STAT orders appropriately
Monitoring upcoming appointment schedules to ensure required authorizations and referrals are obtained prior to patient visits
Proactively identifying authorization gaps and escalates time-sensitive cases as needed
Verifying patient insurance benefits and authorization requirements
Entering or verifying patient financial responsibility in Clearwave for check-in, or contacts patients directly to review and collect applicable balance
Submitting authorization requests to third-party payers in accordance with plan requirements
Coordinating with PCP offices, patients, and internal clinical teams to obtain necessary referrals and supporting documentation
Tracking and following up on pending authorizations within established timelines
Submitting additional clinical documentation and medical records to payers as requested
Facilitating peer-to-peer reviews between providers and payers when require
Scheduling outside diagnostic testing when applicable and provides patients with accurate appointment details
Transmitting referral authorizations and supporting office notes to external providers in a timely manner
Communicating authorization status clearly with patients, including approvals, delays, and denials
Notifying patients in advance when authorization has not been obtained and assists with rescheduling as appropriate
Accurately documenting all authorization and referral activity in the patient’s NextGen medical record
Ensuring data integrity across systems and proper use of required fields
Scheduling follow-up appointments with the ordering provider after external diagnostic testing is completed
Confirming patients receive clear instructions regarding next steps in care
Providing cross-coverage within the Authorization team
Assisting with insurance verification and surgical authorizations as needed
Maintaining strong working knowledge of payer plans, referral and authorization requirements, benefit structures, and electronic submission processes
Serving as a resource to staff and providers regarding authorization and documentation requirements
Identifying opportunities to improve efficiency and compliance in authorization workflows
Responding promptly and accurately to internal and external inquiries
Escalating complex or recurring issues to management and contributes to process improvement efforts
Representing the practice professionally in all interactions with patients, providers, payers, and external partners
Demonstrating working knowledge of NextGen, Luma, Clearwave, and related platforms
Understanding system integrations and accurately captures required data for authorization tracking and reporting
Performing other related duties as assigned to support department operations