Prior Authorization & Referral Specialist - Athenahealth

Description

University Center for Pain Management is seeking an experienced, detail-oriented Prior Authorization & Referral Specialist with strong working knowledge of Athenahealth and the insurance authorization process. This individual will be responsible for coordinating and managing prior authorizations and referrals for diagnostic imaging, medications, procedures, and other medically necessary services.

The ideal candidate understands the complexities of insurance requirements, can navigate Athenahealth efficiently, communicates effectively with insurance companies and healthcare providers, and proactively follows authorization requests through approval or resolution. Experience in pain management, orthopedics, neurology, gastroenterology, or another specialty practice is preferred.

Position Type: Full-Time Monday-Friday 8AM-4:30PM

Key Responsibilities

1. Athenahealth EHR Management

• Navigate Athenahealth efficiently to manage referrals, authorization requests, patient records, and documentation.
• Enter, update, and track authorization and referral information accurately in the patient's chart.
• Monitor pending requests and maintain organized follow-up records.
• Ensure documentation is complete and available to clinical and administrative staff.
• Utilize Athenahealth work queues, tasks, and available tracking tools to monitor outstanding authorizations.

2. Diagnostic Imaging Authorizations

• Obtain prior authorizations for MRI, CT, X-ray, and other diagnostic imaging services as required by insurance plans.
• Determine insurance-specific requirements, including referrals, clinical documentation, and medical necessity criteria.
• Coordinate with imaging facilities and insurance companies to obtain authorization numbers and approval dates.
• Submit supporting clinical documentation and follow up on pending requests.
• Resolve authorization delays, denials, and requests for additional information.
• Communicate approval status and scheduling requirements to the appropriate team members.

3. Medication Prior Authorizations

• Process medication prior authorizations through insurance portals, electronic systems, and telephone communication.
• Understand formulary requirements, preferred medications, step therapy, quantity limits, and other coverage restrictions.
• Coordinate with pharmacies, insurance companies, and clinical staff when additional information is needed.
• Submit required clinical documentation and monitor requests until a determination is received.
• Assist with appeals and reconsiderations for denied medications, working with the prescribing provider as appropriate.
• Communicate authorization outcomes and next steps to the clinical team.

4. Referrals and Procedure Authorizations

• Process specialist referrals and insurance-required authorizations.
• Verify referral requirements and confirm that necessary documentation is submitted.
• Obtain authorizations for covered procedures and services, as applicable to the practice.
• Track expiration dates, approved service limits, and authorization requirements.
• Coordinate with referring providers, receiving facilities, and insurance representatives to resolve outstanding issues.

5. Insurance Verification and Follow-Up

• Verify insurance eligibility and benefits relevant to referrals, imaging, medications, and procedures.
• Identify payer-specific authorization requirements before services are scheduled when possible.
• Contact commercial insurance plans, Medicare Advantage plans, and other payers as appropriate.
• Maintain an accurate log of pending, approved, denied, and appealed requests.
• Escalate complex denials or unresolved cases to the practice manager or clinical team.
• Communicate delays and authorization status changes promptly to appropriate staff.

6. Denial Management and Compliance

• Identify reasons for authorization denials and determine the administrative steps needed for resolution.
• Prepare and submit reconsiderations or appeals using documentation provided or approved by the clinical team.
• Maintain complete, accurate, and timely documentation of all authorization activities.
• Protect confidential patient information and comply with HIPAA requirements.
• Follow payer policies and practice procedures without independently making clinical medical-necessity determinations.

Requirements

Required Qualifications

• Previous experience in medical prior authorizations, referrals, or insurance authorization coordination.
• Demonstrated working knowledge of Athenahealth.
• Hands-on experience obtaining authorizations for diagnostic imaging and medications.
• Familiarity with insurance portals, payer guidelines, and authorization tracking.
• Strong organizational skills and the ability to manage multiple requests and deadlines.
• Excellent written, verbal, and telephone communication skills.
• Ability to work independently, troubleshoot problems, and follow requests through to completion.
• Strong attention to detail and accurate documentation practices.

Preferred Qualifications

• Experience in a specialty medical practice, preferably pain management.
• Experience with MRI and CT authorizations, prescription medication prior authorizations, and procedure approvals.
• Familiarity with pharmacy benefit managers and electronic medication authorization workflows.
• Experience handling denials, appeals, and peer-to-peer review coordination.
• Knowledge of Medicare Advantage, commercial insurance, and other payer requirements.
• Experience managing high-volume authorization requests in a fast-paced medical office.

Measures of Success

The successful candidate will demonstrate the ability to:

• Reduce delays in obtaining authorizations.
• Maintain an organized system for tracking pending requests.
• Follow up consistently on outstanding authorizations and denials.
• Ensure requests are submitted with the appropriate documentation.
• Communicate clearly with providers, staff, insurers, pharmacies, and imaging facilities.
• Help prevent avoidable appointment cancellations and treatment delays caused by incomplete authorization work.