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Authorization Representative - Gainesville
Summary
Handles insurance referrals and authorizations for orthopaedic patients, verifying coverage and documenting approvals before appointments.
Position Summary: The Authorization Representative is responsible for the end-to-end coordination, verification, and management of patient referrals and prior authorizations to ensure timely access to care and compliance with payer requirements. This role serves as a key liaison between physician offices, insurance carriers, and patients to secure necessary approvals for office visits, procedures, specialty injections, and diagnostic services. The position plays a critical role in supporting operational efficiency, patient experience, and appropriate reimbursement for services rendered.
Compensation:
- $20.00 - $22.00 per hour
Key Responsibilities:
Referral & Authorization Management
- Manage the full lifecycle of referrals and prior authorizations for scheduled patient services
- Determine authorization requirements for office visits, procedures, specialty injections, and diagnostic testing based on payer guidelines
- Coordinate with primary care physician (PCP) offices and insurance carriers to secure required referrals prior to service dates
- Ensure all authorizations are secured and validated prior to patient appointments to prevent delays in care
- Clarify and interpret physician orders to ensure appropriate authorization routing and compliance
Insurance Verification & Payer Engagement
- Navigate payer portals (e.g., Availity, TRICARE/Humana Military, UnitedHealthcare, and others) to secure authorizations and referrals
- Maintain active access and proficiency across multiple insurance carrier systems
- Verify patient eligibility and benefits in Athena prior to scheduled services
- Submit and track clinical documentation required to support authorization requests for diagnostic studies and procedures
Clinical Documentation & Record Integrity
- Review and analyze clinical documentation (physician notes, treatment history, conservative therapy outcomes) to support authorization submissions
- Maintain accurate and complete records within Incision, assuming ownership of assigned provider queues
- Ensure all referral and authorization data is accurately documented in EMR systems (Athena and Incision)
- Support billing integrity by maintaining complete authorization documentation for reimbursement purposes
- Ensure all work is completed within established timelines and compliance standards
Patient & Provider Communication
- Serve as a professional point of contact for patients regarding referral status, authorization updates, and scheduling impacts
- Proactively communicate delays or authorization barriers and assist with rescheduling as needed
- Collaborate effectively with physician offices, hospitals, diagnostic centers, and insurance representatives to resolve authorization issues
- Partner with front desk and clinical teams to ensure authorization readiness prior to patient visits
Qualifications:
- High school diploma or equivalent required
- 1–3 years of experience in a clinical, medical billing, or revenue cycle environment
- Experience working with medical terminology and healthcare administrative workflows
- Proficiency with electronic health record (EHR) systems required
- Knowledge of third-party payers, including Medicare, Medicaid, and commercial HMO plans
Preferred Qualifications & Skills:
- Prior experience with referrals, prior authorizations, or insurance verification strongly preferred
- Strong understanding of payer guidelines and managed care processes
- Excellent customer service and communication skills in a healthcare setting
- Ability to manage high call volumes and competing priorities in a fast-paced environment
- Strong attention to detail and data entry accuracy
- Proficiency navigating multiple insurance portals and payer systems
- Ability to analyze, interpret, and integrate clinical documentation to support authorization requests
- Strong organizational and time management skills
- Ability to build effective working relationships with internal and external stakeholders
Orthopaedic Solutions Management is a Drug Free Workplace
We are committed to maintaining a safe, healthy, and productive work environment. As part of this commitment, we operate as a drug-free workplace. All candidates will be required to undergo pre-employment drug screening and/or be subject to random drug testing in accordance with applicable laws and company policy.