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Referral and Authorization Specialist

+ Receives referral requests from providers and Health Plans representatives. Assist in processing medical services request. Completes clerical duties related to the processing of Authorization Requests and Provider Referrals.

+ Verifies member’s eligibility and benefits with subsequent notification to designated staff of eligibility issues.

+ Requests submission of appropriate medical records according to established criteria for requested service(s) in accordance with the corresponding Policy and Procedure.

+ Notifies required parties within the appropriate timeframe for routine and urgent requests for services.

+ Researches member history for duplications and consideration of authorization limits.

+ Provides effective departmental communication with both internal and external sources.

+ Forwards Authorizations to appropriate department staff in terms of eligibility and other coverage, pricing, and benefit issues.

+ Scans, attaches, reviews and effectively works with electronic images as part of the authorization process. Including recording the required information from attachments into the authorization fields.

+ Appropriately forwards all referral requests to the next level of clinical review as applicable and after verifying for completeness and appropriateness.

+ Coordinates approved outpatient surgical procedures in specialist's office and/or outpatient surgical facilities with health plan's authorization department when applicable.

+ Documents and communicates areas of concern to supervisor.

+ Identifies providers who show an educational need to follow national, state and plan requirements.

+ Adheres to company HIPAA policies and procedures. Identifying, maintaining and protecting sensitive HIPAA information (PHI) and following procedures to ensure the security of such information.

• coordinates processes, documents medical referrals and prior authorizations for a variety of medical services for clinic patients, as requested electronically by clinic providers .

• take insurance information from clients and will determine if authorization is necessary for the services that are needed .

Northwest Florida Community Hospital is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at Northwest Florida Community Hospital are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. Northwest Florida Community Hospital will not tolerate discrimination or harassment based on any of these characteristics. We encourage applicants of all ages.

In addition, as part of our commitment to quality and excellence, Northwest Florida Community Hospital will continue to maintain a safe, healthy environment for you by requiring all applicants, who are tentatively selected for a position, to submit to a criminal history check and screening for illegal drug use prior to appointment for a job.

Final confirmation of any job offer will be contingent upon successful completion of all pre-employment requirements, to include undergoing a pre-employment drug screening, and that failure to submit to such screening, the falsification of a screen, or a positive finding on a test will remove the applicant from consideration for employment for one year.