Prior Authorization and Referral Coordination Specialist

Job Duties and Responsibilities:

PCP Referral Management

• Review, submit, and track PCP referral requests through payer, IPA, health plan, and EMR systems to ensure timely patient access to Senseonics services.


• Gather, review, and compile required medical records and supporting documentation to facilitate referral approval.


• Coordinate with PCP offices, specialty providers, care coordinators, and medical records teams to obtain and exchange referral-related documentation.


• Communicate referral requirements and clinical information according to payer and IPA guidelines.


• Monitor referral status and perform proactive follow-up on routine, urgent, and stat referrals until final resolution.


• Follow up on denied, incomplete, or pending referrals and obtain additional documentation required for approval.


• Coordinate referral appointments with provider offices and specialty clinics as needed.


• Maintain accurate documentation of referral activity, appointment status, and patient communications within designated systems.


• Respond to provider, clinic, and internal team inquiries regarding referral status and next steps.


• Verify insurance information and referral eligibility requirements when necessary.


• Stay current with payer, IPA, and referral guideline updates.


• Meet established productivity, quality, and turnaround time standards.

Prior Authorization Management

• Review patient insurance coverage and determine prior authorization requirements for Senseonics products and services.


• Prepare, submit, and track authorization requests according to payer-specific requirements.


• Gather and submit supporting clinical documentation required for medical necessity review.


• Coordinate with provider offices, payers, and internal stakeholders to facilitate timely authorization approval.


• Identify health plans that require authorizations to be submitted directly by the PCP, referring provider, or servicing provider.


• Partner with PCP offices to ensure authorization requests are submitted timely and with complete clinical documentation when direct submission by Senseonics support staff is not permitted.


• Monitor authorization status, conduct follow-up activities, and document all payer communications and reference numbers.


• Communicate approval, denial, cancellation, and pending authorization status to providers and internal stakeholders.


• Follow up on denied authorizations and coordinate resubmissions, corrections, or additional documentation requests as appropriate.


• Escalate urgent cases and authorization barriers that may impact patient access to therapy.


• Maintain accurate case documentation and ensure compliance with HIPAA, client requirements, and established service level agreements (SLAs).


• Meet authorization turnaround time, quality, and productivity expectations.

Job Required Qualification:

• Minimum 3-year solid experience with US Healthcare Insurance


• At least 1 year work experience in a customer service call center (Voice and Back office)


• Strong knowledge on doing Members and provider outreach/calling.


• Familiarity with EMR, DME systems, payer portals, and database entry


• Strong understanding of HIPAA compliance and medical terminology


• Ability to manage high volume workloads and meet performance targets


• Proficiency in MS Word, Excel, and Outlook


• Experience and Exposure with medical Insurance/Benefits investigation and Authorizations.


• High attention to detail and documentation accuracy


• Excellent Customer service skills, including phone and interpersonal skills.


• Typing speed of at least 35 WPM with high accuracy


• Database data entry experience preferred.


• Strong English proficiency, both written and verbal


• Strong attendance, reliability, and accountability


• Ability to work effectively with diverse teams and clients


• High comfort level working with culturally diverse team members and clients.


• Proficient mathematical skills, including addition, subtraction, multiplication, and division.

Preferred Qualifications:

• Startup / rapid growth experience


• Life sciences, pharmaceutical, or medical device experience.


• Knowledge of medical terminology preferred.


• Knowledge on DME products (e.g Diabetes Supplies)