Top 1 Pre authorization specialist Jobs in Holland Mi

Pre-Authorization Specialist
Shoreline Orthopaedics —Holland, MI
- HIPAA
- Mid-level
- High school diploma or GED
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Pre-Authorization Specialist

Shoreline Orthopaedics -
Holland, MI

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Job Details

Qualifications

Medicare
Medical insurance coverage verification
Practice management software
High school diploma or GED
Medicaid health insurance
ICD-10
Medicaid

Full Job Description

Description:

The Preauthorization Specialist is responsible for prior authorizations for orthopaedic services. They will verify insurance, ensure medical necessity, submit and track requests, communicate outcomes, and support care coordination. They will maintain accurate documentation, assist with appeals, educate patients on coverage, and ensure HIPAA compliance.

Key Responsibilities:

Obtain prior authorizations and referrals for orthopaedic surgeries, procedures, diagnostic imaging (MRI, CT, X-ray), injections, DME, and therapies
Verify patient insurance eligibility, benefits, and authorization requirements
Review clinical documentation to ensure medical necessity criteria are met
Submit authorization requests through payer portals, phone, or fax and track status to completion
Communicate authorization approvals, denials, and requests for additional information to providers and staff
Work closely with physicians, clinical staff, surgery schedulers, and billing teams to prevent delays in care
Appeal denied or partially approved authorizations when appropriate
Maintain accurate and timely documentation in the electronic health record (EHR) and practice management systems
Stay current on payer policies, orthopaedic procedure requirements, and authorization guidelines
Assist patients by explaining authorization processes, coverage limitations, and potential financial responsibility
Ensure compliance with HIPPA/regulatory requirements

Requirements:

High school diploma or equivalent required
Minimum of 1–2 years of experience in medical preauthorization, referrals, or insurance verification
Experience in orthopaedics or a surgical specialty strongly preferred
Knowledge of CPT, ICD-10, and medical necessity guidelines
Familiarity with major commercial payers, Medicare, and Medicaid
Proficiency with EHR and insurance web portals

Preferred Qualifications

Certified Professional Biller/Coder (CPB/CPC), Certified Medical Administrative Assistant (CMAA), or similar certification preferred
Experience with surgical authorizations and appeals
Understanding of workers’ compensation and motor vehicle accident claims

Working & Environmental Conditions:

Primarily in an indoor clinical/office setting with moderate noise levels. Occasional lifting of 50 pounds is required. The role may require prolonged periods of standing and frequent use of computer equipment. This role requires the usage of personal protective equipment and requires in-person attendance.

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Pre-Authorization Specialist

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