SPECIALIST, AUTHORIZATION & REFERRAL

Decatur County Memorial Hospital Authorization Referral Specialist

At Decatur County Memorial Hospital (DCMH), we are more than a healthcare providerwe are a trusted community partner committed to improving the health and well-being of the individuals and families we serve. As a critical access hospital, DCMH combines high-quality patient care, advanced medical services, and a compassionate, patient-centered approach in a welcoming rural healthcare environment. Our team is made up of dedicated professionals who are passionate about making a difference every day. We foster a culture of collaboration, respect, integrity, and continuous improvement, where employees are empowered to grow professionally while contributing to exceptional patient outcomes. DCMH offers competitive compensation and benefits, opportunities for professional development, and a supportive workplace that values each team members contributions.

POSITION SUMMARY

Reports To: Authorization Manager

Summary: The Authorization Referral Specialist is responsible for coordinating all aspects of the prior authorization and referral process. This includes insurance and benefit verification, obtaining authorizations for internal services and referrals to outside providers, gathering necessary clinical documentation to meet payer requirements, and ensuring timely processing to support continuity of care and reimbursement. This position works collaboratively with providers, referral coordinators, insurance companies, and patients to ensure that all services whether performed within the organization or by external specialists, meet payer authorization requirements. The specialist contributes to the development and maintenance of standardized workflows for both prior authorizations and referrals across the organization and is expected to participate in cross-training initiatives to support departmental flexibility and coverage.

Work Schedule: Standard work schedule.

SKILLS AND ABILITIES

Education: High school education or GED. Two years college preferred.

Experience: Six months previous experience in customer service. Knowledge of medical coding.

Computer Skills: Proficient in Microsoft Office, email and basic computer skills for other software used throughout the hospital for your area of responsibility.

Certificates, Licenses: N/A

Other Requirements: Familiarity with medical terminology or willingness to learn. This position requires constant sitting, use of hands and fingers, reaching outward, lifting and carrying 0-10 lbs.

ESSENTIAL FUNCTIONS

Insurance verification and benefit coverage.

Review provider orders to determine whether prior authorization is required for services rendered within the organization or for referrals to outside specialists, facilities, or ancillary services.

Obtain and submit prior authorization requests following payer-specific processes, including submission of required clinical documentation.

Coordinate outgoing referrals to outside providers and internal, including: Ensuring completeness of referral documentation Confirming insurance network participation Verifying authorization requirements Communicating authorization status to the receiving provider

Track, document, and communicate authorization and referral status in the EHR in a timely and accurate manner.

Review authorization denials; communicate reasons to appropriate staff; initiate appeals, retro authorizations, or reconsiderations when appropriate.

Maintain ongoing communication with payers, patients, internal departments, and external provider offices to prevent delays in care.

Answer incoming calls related to authorizations and referrals, provide routine information, and route calls appropriately.

Maintain accurate entry of non-clinical and structured clinical data into appropriate systems and payer portals.

Remain current on payer updates, referral requirements, and authorization guidelines to ensure compliance and reimbursement accuracy.

Participate in cross-training to support both referral coordination and prior authorization workflows to promote departmental flexibility and coverage.

Support and participate in organizational quality improvement and performance initiatives.