JOB SUMMARY
We are seeking an experienced Insurance Verification & Authorization Specialist with a strong background in the medical field to support our revenue cycle and patient intake operations. The ideal candidate will have hands-on experience verifying insurance benefits, checking authorization requirements, obtaining prior authorizations, and submitting and following up on Primary Care Provider (PCP) referrals.
This role requires strong attention to detail, excellent communication skills, and the ability to follow up consistently with insurance companies, provider offices, and internal teams to ensure all requirements are met before services or equipment are provided.
Previous experience in medical insurance verification, prior authorizations, and PCP referral coordination is required.
KEY RESPONSIBILITIES
1. INSURANCE VERIFICATION
- Verify patients' insurance eligibility and active coverage.
- Review insurance benefits, including deductibles, copayments, coinsurance, and out-of-pocket expenses.
- Confirm in-network and out-of-network benefits and provider participation.
- Identify coverage limitations, exclusions, and payer-specific requirements.
- Determine whether prior authorizations or PCP referrals are required.
- Document verification results accurately in the appropriate systems.
- Communicate insurance findings and potential patient financial responsibilities to the appropriate internal teams.
2. AUTHORIZATION CHECKS AND FOLLOW-UPS
- Review insurance policies to determine prior authorization requirements for medical services, supplies, or durable medical equipment (DME).
- Submit authorization requests with the required documentation.
- Follow up with insurance companies and utilization management departments regarding pending authorizations.
- Track authorization status, approval dates, expiration dates, and approved service periods.
- Identify missing documentation or additional information needed to complete authorization requests.
- Escalate delayed, denied, or urgent authorization requests as needed.
- Maintain accurate records of authorization submissions, follow-ups, and payer responses.
- Communicate authorization updates and requirements to internal departments.
3. PCP REFERRAL SUBMISSIONS AND FOLLOW-UPS
- Verify whether a patient's insurance plan requires a referral from their Primary Care Provider (PCP).
- Contact PCP offices to request and obtain required referrals.
- Submit referral requests and supporting documentation according to payer requirements.
- Follow up with provider offices and insurance companies on outstanding referrals.
- Track referral submission dates, approval status, effective dates, and expiration dates, when applicable.
- Resolve referral issues, including missing information, incorrect provider details, and processing delays.
- Ensure referrals are documented and available before proceeding with applicable services or orders.
4. DOCUMENTATION AND COMMUNICATION
- Maintain accurate and timely documentation in electronic systems.
- Manage assigned work queues and prioritize pending requests based on urgency and aging.
- Communicate professionally with insurance representatives, medical offices, and internal teams.
- Follow established workflows and payer-specific guidelines.
- Identify recurring insurance, authorization, and referral issues and report them to management.
- Protect confidential patient information and comply with HIPAA requirements.
REQUIRED QUALIFICATIONS
- Previous hands-on experience in the medical field is required.
- Must be available to work on-site in Birmingham, AL, for a minimum of 30 hours per week.
- Experience with medical insurance eligibility and benefits verification.
- Experience checking and obtaining prior authorizations.
- Experience submitting PCP referrals and following up with provider offices.
- Knowledge of commercial insurance and government healthcare plans, such as Medicare and Medicaid.
- Understanding of in-network benefits, deductibles, coinsurance, referral requirements, and authorization processes.
- Strong organizational skills and attention to detail.
- Excellent written and verbal communication skills.
- Ability to manage multiple requests and follow up on outstanding items without constant supervision.
- Proficiency with computers, spreadsheets, and electronic documentation systems.
- Ability to handle confidential patient information in accordance with HIPAA requirements.
PREFERRED QUALIFICATIONS
- Experience working with durable medical equipment (DME), medical supplies, or healthcare revenue cycle operations.
- Experience with insurance portals and eligibility verification tools.
- Familiarity with electronic health records (EHRs), practice management systems, and ticketing or CRM platforms.
- Experience working directly with insurance companies, medical offices, and provider referral departments.