About the Position
We are seeking a detail-oriented, organized, and proactive Insurance Authorization & Claims Specialist to join our orthopedic practice.
This position is responsible for managing insurance authorizations and referrals from start to finish, while also resolving authorization-related claim issues that can delay or prevent reimbursement. The specialist will work closely with providers, clinical staff, patients, insurance companies, and the Revenue Cycle Management (RCM) team.
This is an important revenue-protection role focused on preventing avoidable authorization issues, resolving claim-related problems, and ensuring the practice receives appropriate reimbursement.
Key Responsibilities
- Front desk position assisting with answering phones and checking out patients
- Verify insurance eligibility, benefits, referral requirements, and authorization requirements.
- Obtain and track prior authorizations for orthopedic procedures, surgery, physical therapy, imaging, medications, injections, and other services.
- Obtain required PCP and specialist referrals.
- Submit required clinical documentation and follow up with payers on pending authorizations.
- Track authorization numbers, approved services, units/visits, effective dates, and expiration dates.
- Identify authorization issues before services are rendered whenever possible.
- Work authorization-related claim edits, rejections, and holds routed by the RCM team.
- Research claims requiring insurance follow-up related to authorization, referral, or documentation issues.
- Correct authorization and referral discrepancies and coordinate with the RCM team for claim resubmission.
- Identify missing or incomplete documentation and coordinate with clinical staff to obtain necessary records.
- Communicate directly with insurance companies and document payer conversations, reference numbers, and resolutions.
- Identify potential underpayments or reimbursement discrepancies related to authorization or payer requirements and communicate findings to the RCM team.
- Identify recurring payer, authorization, referral, and documentation issues and recommend process improvements.
- Maintain accurate documentation and comply with HIPAA and all applicable healthcare regulations.
How This Role Works With RCM
The RCM team manages the overall claims, denials, and accounts receivable workflow. When RCM identifies a claim issue specifically related to an authorization, referral, or authorization-related documentation requirement, the claim is routed to the specialist's Authorization/Claims Hold Bucket.
The specialist is responsible for researching and resolving the issue and communicating the resolution back to RCM so the claim can continue through the billing and reimbursement process.
What We're Looking For
Required:
- 2+ years of experience in medical billing, insurance authorization, claims processing, or a related healthcare role.
- Medical office experience.
- Prior authorization, referral, and insurance experience.
- Knowledge of CPT, HCPCS, ICD-10-CM, and medical terminology.
- Understanding of commercial insurance, Medicare, and Medicaid requirements.
- Strong attention to detail and problem-solving skills.
- Excellent communication and organizational skills.
- Ability to work independently and manage multiple priorities.
- Experience using payer portals and electronic health record systems.
Preferred:
- Orthopedic practice experience.
- Physical therapy authorization/billing experience.
- Experience with surgical authorizations.
- Athena EHR experience.
- Experience with claim edits, rejections, denials, appeals, or underpayment identification.
- Experience working with Medicare Advantage and commercial payers.
What Success Looks Like
Success in this role means getting authorizations completed accurately and on time, preventing avoidable authorization-related denials, resolving claim holds efficiently, identifying reimbursement issues, and helping the practice continuously improve its insurance and revenue-cycle processes.
If you are an organized, analytical healthcare professional who enjoys solving insurance and claims problems and taking ownership of issues through resolution, we would love to hear from you.
Apply today to join our team!
Pay: $20.00 - $25.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
