Authorization Specialist

• Insurance Benefits & Eligibility: Interpret insurance plans, Summary of Benefits (SOB), exclusions, insurance cards, network eligibility, patient financial responsibility, and preauthorization requirements. • Referral & Preauthorization Management: Process referrals and authorization requests accurately and promptly, utilizing insurance portals and following payer-specific requirements. • Medical Records & Coding: Review medical records, patient history, diagnoses, and treatment plans; ensure appropriate ICD-10, CPT, HCPCS, CDT codes, and medical necessity documentation. • Communication & Coordination: Communicate effectively with patients, insurance payers, physicians, clinical teams, and external healthcare facilities to obtain required information and provide authorization updates. • Workflow & Timely Processing: Monitor EMR referral queues, follow established Lean workflows, resolve pending requests within acceptable timeframes, and minimize delays in patient care. • Denial Management & Compliance: Coordinate with Financial Counselors on denied requests, manage retro-authorizations where appropriate, escalate payer-related trends, and comply with DOH adjudication rules and departmental quality standards. • Performance & Teamwork: Meet clients core competencies, departmental KPIs, and productivity goals; educate clinicians on authorization requirements, demonstrate teamwork, and perform other assigned duties. • High School Diploma or GED required; Associate's or Bachelor's degree in healthcare administration or a related field preferred. • Minimum of 5-7 years of direct experience in healthcare insurance verification and authorization. • Proficiency in utilizing Electronic Health Record (EHR) and practice management software. • Strong understanding of medical terminology, CPT, HCPCS, and ICD-10 coding principles.