Authorization Representative - Gainesville

Job Description

Job Description

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.