Insurance Verification & Authorization Specialist

We are seeking an experienced Insurance Verification & Authorization Specialist with a strong background in the medical field to support our revenue cycle and patient intake operations. The ideal candidate will have hands-on experience verifying insurance benefits, checking authorization requirements, obtaining prior authorizations, and submitting and following up on Primary Care Provider (PCP) referrals.

This role requires strong attention to detail, excellent communication skills, and the ability to follow up consistently with insurance companies, provider offices, and internal teams to ensure all requirements are met before services or equipment are provided.

• Verify patients' insurance eligibility and active coverage.

• Review insurance benefits, including deductibles, copayments, coinsurance, and out-of-pocket expenses.

• Confirm in-network and out-of-network benefits and provider participation.

• Identify coverage limitations, exclusions, and payer-specific requirements.

• Determine whether prior authorizations or PCP referrals are required.

• Document verification results accurately in the appropriate systems.

• Communicate insurance findings and potential patient financial responsibilities to the appropriate internal teams.

• Review insurance policies to determine prior authorization requirements for medical services, supplies, or durable medical equipment (DME).

• Submit authorization requests with the required documentation.

• Follow up with insurance companies and utilization management departments regarding pending authorizations.

• Track authorization status, approval dates, expiration dates, and approved service periods.

• Identify missing documentation or additional information needed to complete authorization requests.

• Escalate delayed, denied, or urgent authorization requests as needed.

• Maintain accurate records of authorization submissions, follow-ups, and payer responses.

• Communicate authorization updates and requirements to internal departments.

• Verify whether a patient's insurance plan requires a referral from their Primary Care Provider (PCP).

• Contact PCP offices to request and obtain required referrals.

• Submit referral requests and supporting documentation according to payer requirements.

• Follow up with provider offices and insurance companies on outstanding referrals.

• Track referral submission dates, approval status, effective dates, and expiration dates, when applicable.

• Resolve referral issues, including missing information, incorrect provider details, and processing delays.

• Ensure referrals are documented and available before proceeding with applicable services or orders.

• Maintain accurate and timely documentation in electronic systems.

• Manage assigned work queues and prioritize pending requests based on urgency and aging.

• Communicate professionally with insurance representatives, medical offices, and internal teams.

• Follow established workflows and payer-specific guidelines.

• Identify recurring insurance, authorization, and referral issues and report them to management.

• Protect confidential patient information and comply with HIPAA requirements.

• • Experience working with durable medical equipment (DME), medical supplies, or healthcare revenue cycle operations.

  • Experience with insurance portals and eligibility verification tools.

  • Familiarity with electronic health records (EHRs), practice management systems, and ticketing or CRM platforms.

  • Experience working directly with insurance companies, medical offices, and provider referral departments.