Authorization Representative - Gainesville

Position Summary: The Authorization Representative is responsible for the end-to-end coordination, verification, and management of patient referrals and prior authorizations to ensure timely access to care and compliance with payer requirements. This role serves as a key liaison between physician offices, insurance carriers, and patients to secure necessary approvals for office visits, procedures, specialty injections, and diagnostic services. The position plays a critical role in supporting operational efficiency, patient experience, and appropriate reimbursement for services rendered.

Compensation:

• $20.00 - $22.00 per hour

Key Responsibilities:

Referral & Authorization Management

• Manage the full lifecycle of referrals and prior authorizations for scheduled patient services
• Determine authorization requirements for office visits, procedures, specialty injections, and diagnostic testing based on payer guidelines
• Coordinate with primary care physician (PCP) offices and insurance carriers to secure required referrals prior to service dates
• Ensure all authorizations are secured and validated prior to patient appointments to prevent delays in care
• Clarify and interpret physician orders to ensure appropriate authorization routing and compliance

Insurance Verification & Payer Engagement

• Navigate payer portals (e.g., Availity, TRICARE/Humana Military, UnitedHealthcare, and others) to secure authorizations and referrals
• Maintain active access and proficiency across multiple insurance carrier systems
• Verify patient eligibility and benefits in Athena prior to scheduled services
• Submit and track clinical documentation required to support authorization requests for diagnostic studies and procedures

Clinical Documentation & Record Integrity

• Review and analyze clinical documentation (physician notes, treatment history, conservative therapy outcomes) to support authorization submissions
• Maintain accurate and complete records within Incision, assuming ownership of assigned provider queues
• Ensure all referral and authorization data is accurately documented in EMR systems (Athena and Incision)
• Support billing integrity by maintaining complete authorization documentation for reimbursement purposes
• Ensure all work is completed within established timelines and compliance standards

Patient & Provider Communication

• Serve as a professional point of contact for patients regarding referral status, authorization updates, and scheduling impacts
• Proactively communicate delays or authorization barriers and assist with rescheduling as needed
• Collaborate effectively with physician offices, hospitals, diagnostic centers, and insurance representatives to resolve authorization issues
• Partner with front desk and clinical teams to ensure authorization readiness prior to patient visits

Qualifications:

• High school diploma or equivalent required
• 1-3 years of experience in a clinical, medical billing, or revenue cycle environment
• Experience working with medical terminology and healthcare administrative workflows
• Proficiency with electronic health record (EHR) systems required
• Knowledge of third-party payers, including Medicare, Medicaid, and commercial HMO plans

Preferred Qualifications & Skills:

• Prior experience with referrals, prior authorizations, or insurance verification strongly preferred
• Strong understanding of payer guidelines and managed care processes
• Excellent customer service and communication skills in a healthcare setting
• Ability to manage high call volumes and competing priorities in a fast-paced environment
• Strong attention to detail and data entry accuracy
• Proficiency navigating multiple insurance portals and payer systems
• Ability to analyze, interpret, and integrate clinical documentation to support authorization requests
• Strong organizational and time management skills
• Ability to build effective working relationships with internal and external stakeholders

Orthopaedic Solutions Management is a Drug Free Workplace

We are committed to maintaining a safe, healthy, and productive work environment. As part of this commitment, we operate as a drug-free workplace. All candidates will be required to undergo pre-employment drug screening and/or be subject to random drug testing in accordance with applicable laws and company policy.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.