Prior Authorization & PCP Referral Coordinator

Job Overview

We are seeking a highly organized, detail-oriented, and proactive Prior Authorization & PCP Referral Coordinator to join our healthcare operations team. This role is responsible for managing all prior authorizations and Primary Care Physician (PCP) referrals throughout the business day to ensure patients receive timely care while minimizing treatment delays.

The ideal candidate has experience working with U.S. healthcare insurance, prior authorization processes, and referral management. They possess strong organizational skills, excellent attention to detail, and the ability to prioritize multiple requests in a fast-paced medical environment.

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Work Schedule

• Full-Time
• Monday to Friday
• Office Hours (Eastern Standard Time - EST)

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Key Responsibilities

Prior Authorization Management

• Monitor uploaded superbills throughout the day to identify services requiring prior authorization.
• Review all designated CPT codes that require insurance authorization.
• Submit prior authorization requests through insurance portals or contact insurance companies by phone when necessary.
• Utilize the provided diagnosis codes and supporting clinical documentation to complete authorization requests.
• Process authorization requests promptly as they are received to prevent backlogs.
• Prioritize same-day authorizations for services performed on the current day whenever possible.
• Accurately document authorization numbers, approval dates, insurance reference numbers, and related information within the patient's electronic medical record (EMR).
• Follow up on pending authorizations to ensure timely approvals and minimize delays in patient care.

PCP Referral Coordination

• Verify whether patients with HMO insurance plans require Primary Care Physician (PCP) referrals prior to their appointments.
• Contact patients and/or PCP offices to obtain required referrals before scheduled appointments whenever possible.
• Follow up on outstanding referral requests throughout the day until resolved.
• Record referral numbers, expiration dates, and all relevant information accurately within the patient's EMR.
• Coordinate with providers, front office staff, and insurance representatives to resolve referral-related issues efficiently.

Documentation & Communication

• Maintain accurate, complete, and up-to-date documentation within the EMR.
• Immediately communicate authorization delays, insurance issues, or referral concerns to management.
• Ensure all assigned authorizations and referrals are completed by the end of each business day whenever possible.
• Maintain confidentiality and compliance with HIPAA and organizational policies.

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Qualifications

Required

• Previous experience in Prior Authorization, Medical Insurance Verification, Referral Coordination, Medical Billing, or a similar healthcare administrative role.
• Strong understanding of U.S. health insurance plans, including HMO, PPO, Medicare, and Medicaid.
• Experience working with CPT, ICD-10, and diagnosis codes.
• Familiarity with electronic medical records (EMR/EHR) systems.
• Excellent verbal and written English communication skills.
• Strong organizational, multitasking, and time-management abilities.
• High attention to detail and accuracy.
• Ability to work independently while managing multiple priorities throughout the day.

Preferred

• Experience working in specialty medical practices.
• Familiarity with insurance portals and payer authorization systems.
• Knowledge of medical terminology and healthcare workflows.

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What Success Looks Like

• Prior authorizations are submitted and completed promptly without unnecessary delays.
• PCP referrals are obtained before patient appointments whenever possible.
• Patient records remain accurate and up to date.
• Insurance approvals and referral documentation are consistently tracked and recorded.
• Communication with patients, providers, and insurance companies remains timely and professional.
• Daily workloads are completed efficiently, minimizing treatment delays and supporting excellent patient care.

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Ideal Candidate Profile

The ideal candidate is proactive, highly organized, and thrives in a fast-paced healthcare environment. They take ownership of the authorization and referral process, communicate effectively with patients and insurance providers, and consistently maintain accurate documentation while ensuring patients receive timely access to care.