Authorization Representative

Job Title :    Authorization Representative                                            

Department :  Clinical Support                                                    

Reports To :  Clinic Support Supervisor                                                    

FLSA Status : Non-exempt (hourly)                                                           

Work Schedule:  Monday-Friday, 8:00 A.M. - 5:00 P.M.                                                      

Summary :    Secure pre-authorization for patients for MRI, PT, injections, in-house procedures and surgeries. Will also need to support obtaining pre-authorizations for urgent or special surgical cases.

This position requires compliance with OrthoEast’s compliance standards, including its Code of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element required as part of the job duties, and considered during performance evaluations.                                 

Essential Duties and Responsibilities : include the following.

This is a full-time position which requires consistent attendance, being on time, and conforming to the work schedule as described above.

• Verify Insurance Coverage: Review and verify insurance information provided by patients to ensure coverage for medical procedures, treatments, or services.


• Obtain Prior Authorizations: Communicate with insurance companies and other relevant parties to obtain necessary prior authorizations for medical procedures or treatments as required.


• Documentation and Record-Keeping: Maintain accurate and up-to-date records of authorization requests, approvals, and denials. Ensure all documentation is complete, organized, and compliant with relevant regulations.


• Communication with Healthcare Providers: Collaborate with healthcare providers, such as physicians, nurses, and medical staff, to gather necessary information for authorization requests and to resolve any issues or discrepancies.


• Patient Education: Inform and educate patients about their insurance coverage, authorization requirements, and any financial responsibilities they may have related to their medical services.


• Insurance Claims Management: Assist in the claims process by ensuring proper authorization documentation is submitted and follow up on any pending claims or denials related to authorizations.


• Compliance with Regulations: Stay updated on healthcare regulations, insurance policies, and industry changes to ensure compliance in all authorization-related activities.


• Problem-solving and Troubleshooting: Proactively identify and resolve authorization-related issues, including denials or delays, by collaborating with insurance companies, patients, and providers.


• Customer Service: Provide excellent customer service to patients, insurance companies, and providers by promptly addressing inquiries, concerns, and requests related to authorizations.


• Process Improvement: Identify opportunities for process improvement in the authorization workflow, such as streamlining procedures or implementing new technologies, to enhance efficiency and accuracy.


• Other duties as assigned.

Qualifications : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience :

High School diploma or GED required.

Minimum of one year authorization experience preferred

Minimum of one year clerical experience, preferably in a medical office setting, required.

Proficient computer skills required, including Excel, Word, and Outlook.

Experience in maintaining confidentiality in dealing with sensitive issues.

Proven ability in making sound and accurate judgements in problem solving work issues.

Successful record of follow through on commitments and demonstrated dependability.

Required Behaviors:

The physical demands of this position require long periods of sitting, keyboarding, and talking on the telephone.

Good communication skills required in dealing with diverse patient population, often concerning stressful and/or emotional situations.

Ability to prioritize tasks and work independently.

Ability to handle frequent change, delays, and/or unexpected events.

Must be willing to work in a team environment and contribute to building a positive team spirit.

Must be highly organized to successfully manage multiple tasks simultaneously.

Must be able to stay focused during work periods of high patient volume.

Exhibit pleasant, professional telephone etiquette at all times.