FT - Patient Access and Authorization Specialist

Job Description

Position Summary

The Patient Access and Authorization Specialist is responsible for coordinating insurance prior authorizations and referrals for therapy, radiology, and other outpatient hospital services. This position works closely with patients, providers, clinical departments, insurance companies, and physician offices to help ensure services are properly authorized and scheduled without unnecessary delays.

The position also provides administrative support for utilization review and serves as a backup receptionist to support full-time business office and patient access operations.

Essential Duties and Responsibilities

Prior Authorizations and Referrals

• Obtain insurance prior authorizations for physical therapy, occupational therapy, speech therapy, radiology, and other outpatient services as assigned.
• Review physician orders, diagnoses, clinical documentation, insurance information, and medical necessity requirements before submitting authorization requests.
• Submit prior authorization requests through payer websites, telephone systems, fax, or other required methods.
• Track pending authorization requests and follow up with insurance companies until a determination is received.
• Communicate authorization approvals, denials, limitations, and expiration dates to the appropriate hospital department.
• Notify clinical staff when additional documentation, peer-to-peer review, or other action is required.
• Verify that required physician referrals are received and valid before services are provided.
• Coordinate with referring provider offices to obtain missing orders, referrals, clinical notes, or other required documentation.
• Maintain accurate records of authorization numbers, approved visits, effective dates, payer communications, and supporting documentation.
• Monitor authorized visit limits and expiration dates to reduce the risk of providing unauthorized services.
• Assist patients and staff with questions regarding authorization status and insurance requirements.
• Maintain a working knowledge of Medicare, Medicaid, commercial insurance, managed care, and other payer requirements.

Utilization Review Support

• Provide backup administrative support for utilization review activities.
• Gather and organize clinical and insurance documentation needed for payer reviews.
• Submit requested records and information to insurance companies within required timeframes.
• Track inpatient, observation, swing bed, and other utilization review requests as assigned.
• Document payer communications, reference numbers, review status, and determinations.
• Communicate requests for additional clinical information to nursing, providers, health information management, or other appropriate staff.
• Escalate clinical questions and medical necessity determinations to the qualified nurse, provider, or utilization review professional.
• Assist with tracking denials, appeals, concurrent reviews, and continued-stay authorization requirements.
• Maintain confidentiality and follow all HIPAA, hospital, and payer requirements.

Reception and Patient Access Coverage

• Serve as a backup receptionist during breaks, lunches, absences, and periods of increased patient volume.
• Greet patients and visitors in a courteous and professional manner.
• Answer and route telephone calls to the appropriate department or staff member.
• Assist with patient registration, demographic updates, insurance verification, and collection of required forms as trained and assigned.
• Provide patients with general information regarding hospital services, appointment locations, and registration procedures.
• Protect patient privacy and maintain confidentiality in all communications.
• Assist with scanning, filing, faxing, copying, and other business office duties as needed.

General Responsibilities

• Work cooperatively with therapy, radiology, nursing, providers, registration, health information management, billing, and other departments.
• Provide timely updates when an authorization or referral issue may delay patient care.
• Maintain accurate and complete documentation in the electronic health record, authorization system, or other designated systems.
• Follow hospital policies, compliance requirements, patient privacy standards, and departmental procedures.
• Participate in training, staff meetings, process improvement activities, and competency requirements.
• Maintain organized work queues and prioritize requests based on scheduled service dates and urgency.
• Perform other duties as assigned.

Minimum Qualifications

• High school diploma or equivalent required.
• At least one year of experience in a medical office, hospital business office, patient access, insurance verification, referrals, billing, or prior authorizations preferred.
• Experience working with insurance companies and payer websites preferred.
• Basic knowledge of medical terminology, insurance plans, and healthcare documentation preferred.
• Experience with electronic health records and Microsoft Office applications preferred.

Knowledge, Skills, and Abilities

• Strong organizational and time-management skills.
• Ability to manage multiple requests, deadlines, and payer requirements.
• Strong written and verbal communication skills.
• Professional and courteous customer service skills.
• Ability to communicate effectively with patients, physician offices, insurance companies, and hospital staff.
• Attention to detail and ability to accurately document authorization information.
• Ability to understand and follow payer guidelines and hospital procedures.
• Ability to work independently while recognizing when an issue should be escalated.
• Ability to maintain patient confidentiality and comply with HIPAA requirements.
• Dependable attendance and flexibility to provide reception coverage when needed.

Working Conditions and Physical Requirements

• Work is primarily performed in a hospital business office and reception environment.
• Regular use of a computer, telephone, fax machine, scanner, and other office equipment is required.
• Must be able to sit or stand for extended periods and occasionally lift or move office materials weighing up to 20 pounds.
• Frequent interaction with patients, visitors, staff, providers, and insurance representatives is required.

Schedule

This is a full-time position. The employee must be available during normal business office hours and provide reception coverage as assigned.