Pre-Cert-Pre-Authorization-Clinic

Pre-Authorization Clerk – Surgery Clinic

Department

Surgery Clinic

Reports To

Clinical Nurse Manager / Department Manager

Job Summary

The Pre-Authorization Clerk is responsible for obtaining insurance authorizations and referrals for surgical procedures, diagnostic services, and other services scheduled through the Surgery Clinic. This position works closely with surgeons, clinical staff, surgical schedulers, patients, insurance companies, and other departments to ensure all required authorizations and documentation are obtained accurately and within established timeframes.

Essential Duties and Responsibilities

• Review scheduled surgical procedures and determine insurance authorization and referral requirements.
• Verify patient insurance eligibility and benefits as needed.
• Obtain prior authorizations for surgical procedures, diagnostic testing, and other services performed through the Surgery Clinic.
• Submit authorization requests through insurance portals, telephone, fax, or other designated systems.
• Gather and submit required clinical documentation, including physician orders, diagnoses, clinical notes, test results, and other supporting information.
• Communicate with insurance companies regarding authorization requirements, pending requests, additional documentation, and authorization determinations.
• Monitor authorization requests and follow up to ensure approvals are obtained prior to the scheduled procedure.
• Accurately document authorization information in the electronic medical record, including authorization numbers, effective dates, expiration dates, reference numbers, and insurance requirements.
• Notify surgical schedulers, nurses, providers, and other appropriate staff of authorization status or issues that may affect the patient's scheduled procedure.
• Identify potential insurance or authorization barriers that could result in delays, rescheduling, or cancellation of procedures and promptly escalate concerns.
• Assist with obtaining physician referrals and other insurance-required documentation.
• Contact physician offices, patients, insurance companies, and other healthcare organizations to obtain necessary information.
• Coordinate with the Surgery Clinic and other hospital departments to ensure patients are appropriately prepared for scheduled procedures.
• Maintain accurate and organized records of authorization requests and determinations.
• Follow organizational policies and procedures related to insurance verification, prior authorization, patient privacy, and HIPAA.
• Maintain confidentiality of patient and insurance information.
• Provide professional, courteous, and timely customer service to patients, providers, insurance representatives, and coworkers.
• Assist with other Surgery Clinic administrative duties as assigned.

Qualifications

• High school diploma or equivalent required.
• Previous healthcare, medical office, insurance verification, scheduling, or prior-authorization experience preferred.
• Previous experience in a surgical or specialty clinic setting preferred.
• Knowledge of medical terminology preferred.
• Knowledge of insurance plans, referrals, and prior-authorization processes preferred.
• Experience with electronic medical records preferred.

Skills and Abilities

• Strong attention to detail and accuracy.
• Excellent organizational and time-management skills.
• Ability to manage multiple authorization requests and competing deadlines.
• Strong verbal and written communication skills.
• Ability to communicate effectively with patients, providers, insurance companies, and clinical staff.
• Ability to work independently and prioritize tasks appropriately.
• Proficient computer skills and ability to navigate multiple electronic systems.
• Ability to recognize and promptly communicate authorization issues that may impact patient care or surgical scheduling.
• Ability to maintain patient confidentiality and handle sensitive information appropriately.

Performance Expectations

The Pre-Authorization Clerk is responsible for ensuring that required insurance authorizations and referrals are obtained accurately and within established timeframes. The position plays an important role in preventing avoidable surgical delays and cancellations by identifying authorization barriers early and communicating issues promptly to the appropriate Surgery Clinic staff.