Authorization & Referral Coordinator

Time Type:

Hours per Pay Period:

Shift:

Minimum:

Maximum:

Department:

Current Bay Area Hospital Employee: If you are a current Bay Area Hospital employee, please apply through the Workday internal career site.

The future looks bright at Bay Area Hospital, and we are always searching for quality people to join our team. We offer a great atmosphere, competitive pay, a wide array of benefits, and many growth opportunities for our employees.

Job Description:

EXPECTATION FOR ALL EMPLOYEES

Supports the organization’s mission, vision, and values by adhering to the behavioral standards of Bay Area Hospital. Comply with all applicable laws, regulations, and organizational policies affecting Bay Area Hospital. Maintains familiarity with and adherence to the Code of Conduct and supports the Bay Area Hospital Compliance Program. Demonstrates effective communication skills and the ability to work collaboratively and professionally with individuals from diverse backgrounds.

POSITION SUMMARY

The Authorization and Referral Coordinator is responsible for coordinating, monitoring, and facilitating authorization, referral, pre-certification, notification, and related payer requirements necessary for scheduled and unscheduled patient services. Serves as a central resource and liaison between physician offices, providers, clinical departments, Case Management, Utilization Review, Patient Access, insurance companies, and other hospital partners to promote timely and accurate financial clearance and minimize barriers to patient care.

Under general supervision, the coordinator evaluates authorization and referral requirements, establishes appropriate workflow and follow-up priorities, coordinates the exchange of required information, monitors outstanding requests, and facilitates resolution of issues that may delay or prevent authorization or referral completion. The position ensures authorization and referral information is accurate, appropriately documented, communicated to affected stakeholders, and aligned with payer, regulatory, departmental, and organizational requirements.

The Authorization and Referral Coordinator Serves as a central resource and liaison for internal and external customers, including physician offices, providers, clinical departments, Case Management, Utilization Review, Patient Access, insurance companies, and other hospital partners, to promote timely and accurate financial clearance and minimize barriers to patient care.

PRINCIPAL DUTIES AND RESPONSIBILITIES

• Coordinates the overall authorization and referral workflow for assigned services, including scheduled and unscheduled services, ensuring requirements are identified, addressed, documented, and communicated within established timelines.
• Serves as a primary coordination point between hospital departments, physician offices, providers, payers, and other stakeholders regarding authorization, referral, pre-certification, notification, and related payer requirements.
• Reviews scheduled services and patient accounts to identify authorization, referral, pre-certification, notification, medical necessity, and other payer requirements and determines appropriate next steps.
• Coordinates with appropriate departments and physician offices to establish responsibility for obtaining required information and completing outstanding payer requirements.
• Reviews payer requirements and determines the appropriate payer-specific process, documentation, and follow-up needed to support authorization or referral completion.
• Coordinates submission of authorization, referral, pre-certification, and notification requests to insurance carriers and other payers, ensuring required documentation and supporting information are available and appropriately submitted.
• Reviews authorization determinations to ensure approved services, procedures, diagnoses, locations, providers, date ranges, units, and other applicable information correspond to the planned or rendered services.
• Coordinates the collection and completion of required physician referrals and supporting documentation and ensures referral information is appropriately recorded.
• Monitors assigned authorization and referral work queues, reports, task lists, pending requests, and other departmental workflows to prioritize outstanding items, identify barriers, and ensure timely progression and resolution.
• Establishes follow-up priorities based on scheduled service dates, payer turnaround times, clinical urgency, and other applicable departmental criteria.
• Follows up with insurance companies and other payers regarding pending, incomplete, or unresolved requests and coordinates next steps when additional information or action is required.
• Reviews authorization and referral information for completeness, accuracy, and consistency; identifies missing or conflicting information and coordinates appropriate correction or follow-up.
• Coordinates the exchange of clinical documentation and other supporting information between providers, physician offices, Case Management, Utilization Review, clinical departments, and payers.
• Communicates authorization and referral status, payer requirements, outstanding documentation, denials, limitations, and potential barriers to appropriate clinical, operational, and physician-office partners.
• Proactively identifies authorization or referral issues that may affect the scheduled date of service and coordinates with appropriate stakeholders regarding available options, including potential rescheduling when necessary and consistent with clinical and departmental processes.
• Coordinates inpatient authorization and notification requirements and facilitates timely communication with payers regarding admissions, continued stays, and other applicable requirements.
• Serves as a resource to Utilization Review, the House Supervisor, physician offices, Patient Access, and other stakeholders regarding payer-specific requirements related to inpatient versus outpatient status and authorization or notification processes.
• Reviews authorization denials and coordinates communication and follow-up with appropriate clinical, operational, and physician-office partners within established notification timelines.
• Coordinates appeals, reconsiderations, peer-to-peer requests, and additional clinical documentation requests, as assigned, by facilitating communication and information exchange between payers, providers, and appropriate hospital departments.
• Assists departments and stakeholders in understanding authorization and referral requirements, status, documentation needs, and other financial clearance barriers.
• Maintains working knowledge of third-party payer requirements, authorization guidelines, referral requirements, medical necessity criteria, insurance contracts, and payer-specific processes.
• Monitors team mailboxes, email inboxes, faxes, telephone calls, work queues, and other communication channels and prioritizes and coordinates responses to authorization and referral issues.
• Maintains close working relationships with Patient Access, Patient Financial Services, clinical departments, physician offices, Case Management, Utilization Review, and other hospital departments to promote effective communication and coordinated resolution of authorization and referral issues.
• Provides professional, efficient, respectful, and customer-focused service to patients, families, providers, physician office staff, payers, co-workers, and other stakeholders through in-person, telephone, and electronic communication.
• Utilizes established communication standards and scenario-specific call scripts when interacting with patients, providers, physician office staff, payers, and other stakeholders.
• Utilizes electronic systems and applications required to coordinate authorization and referral activities, including applicable electronic medical records, authorization and referral management, insurance verification, communication, document management, and scheduling systems.
• Ensure authorization and referral information is accurately and timely documented, including payer contacts, submission dates, reference numbers, authorization determinations, follow-up activity, outstanding requirements, and other applicable information.
• Identifies trends, recurring payer issues, workflow barriers, service-line concerns, and opportunities for process improvement and communicates findings and recommendations to leadership.
• Participate in the development and refinement of authorization and referral workflows, procedures, communication processes, and departmental standards.
• Assists with monitoring departmental performance, including authorization turnaround times, outstanding requests, denials, unresolved issues, and other applicable quality and operational measures.
• Assists with training and orientation of staff, as assigned, and serves as a resource regarding authorization and referral workflows, payer requirements, and departmental processes.
• Assists with departmental reports, audits, process improvement initiatives, payer-related projects, and special projects designed to improve financial clearance, workflow efficiency, communication, and patient access.
• Escalates complex, high-risk, unresolved, or time-sensitive authorization and referral issues to appropriate leadership or subject-matter resources.
• Maintains compliance with HIPAA, Bay Area Hospital policies and procedures, and applicable federal and state laws and regulations.
• Performs other duties as assigned.

SKILLS AND ABILITIES

• Demonstrates strong organizational, coordination, prioritization, and time-management skills with the ability to manage multiple workflows, stakeholders, deadlines, and competing priorities.
• Demonstrates the ability to coordinate work across multiple departments and external organizations while maintaining accountability for follow-up, communication, and resolution.
• Demonstrates strong analytical and problem-solving skills, including the ability to identify barriers, research payer requirements, evaluate options, and coordinate appropriate resolutions.
• Demonstrates strong attention to detail and accuracy when reviewing payer requirements, authorization determinations, referral documentation, and patient account information.
• Demonstrates effective verbal and written communication skills, including the ability to clearly communicate complex payer requirements and issues to diverse audiences.
• Demonstrates professional and effective interpersonal and customer service skills when communicating with internal and external customers, including patients, providers, physician office staff, insurance companies, internal departments, leadership, and other stakeholders.
• Demonstrates the ability to independently organize and coordinate work with minimal supervision and exercise sound judgment regarding priorities, escalation, and follow-up.
• Demonstrates the ability to recognize issues that may affect patient access, financial clearance, reimbursement, or the scheduled date of service and take appropriate action.
• Demonstrates the ability to facilitate resolution of issues through effective communication, collaboration, follow-up, and appropriate escalation.
• Demonstrates proficiency using personal computers, electronic medical records, payer websites, authorization and referral management systems, insurance verification systems, work queues, reporting tools, and other software applications applicable to the position.
• Demonstrates the ability to work collaboratively with multiple departments, providers, physician offices, insurance companies, and external healthcare organizations.
• Demonstrates the ability to identify workflow trends and opportunities for process improvement and communicate observations and recommendations to leadership.
• Maintains regular, consistent, and punctual attendance at the assigned work location.
• Demonstrates keyboarding proficiency of at least 25 words per minute.
• Demonstrates working knowledge of healthcare terminology, health insurance types, eligibility, benefits, authorization and referral requirements, medical necessity, payer processes, and healthcare revenue cycle workflows.

EDUCATION/CERTIFICATIONS/LICENSES/DEGREES

• High school diploma or equivalent required.
• Associate degree or higher education, or completion of relevant college coursework, preferred.
• Relevant healthcare revenue cycle, patient access, medical office, insurance, or authorization/referral certification preferred.

EXPERIENCE

• One (1) year of experience in healthcare Patient Access, Patient Financial Services, insurance verification, referral coordination, medical office operations, healthcare revenue cycle, customer service, or a related area required.
• Previous experience coordinating healthcare authorizations, referrals, pre-certifications, or payer requirements preferred.
• Previous experience working with health insurance companies, payer portals, electronic medical records, referral management systems, healthcare revenue cycle systems, or related applications preferred.
• Experience coordinating work across multiple departments, providers, physician offices, or external organizations preferred.

GENERAL INFORMATION

This is a non-union position.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, qualifications, or job skills required.

PHYSICAL/MENTAL/ENVIRONMENTAL REQUIREMENTS

• Requires extensive sitting with periodic standing and walking.
• May be required to lift and/or carry up to 20 pounds.
• Requires frequent use of a personal computer, telephone, and general office equipment.
• Requires adequate visual acuity and the ability to grasp, handle, and manipulate objects necessary to perform essential job functions.
• Requires the ability to communicate effectively and professionally through reading, writing, speaking, and telephone communication.
• Requires the ability to coordinate multiple workflows, prioritize competing demands, make decisions regarding follow-up and escalation, meet established deadlines, and maintain accuracy in a time-sensitive environment.
• Requires the ability to work effectively with frequent interruptions and changing priorities.
• May require occasional off-site travel.

EXPECTATION FOR ALL EMPLOYEES

Supports the organization’s mission, vision, and values by adhering to the behavioral standards of Bay Area Hospital. Comply with all applicable laws, regulations, and organizational policies affecting Bay Area Hospital. Maintains familiarity with and adherence to the Code of Conduct and supports the Bay Area Hospital Compliance Program. Demonstrates effective communication skills and the ability to work collaboratively and professionally with individuals from diverse backgrounds.

POSITION SUMMARY

The Authorization and Referral Coordinator is responsible for coordinating, monitoring, and facilitating authorization, referral, pre-certification, notification, and related payer requirements necessary for scheduled and unscheduled patient services. Serves as a central resource and liaison between physician offices, providers, clinical departments, Case Management, Utilization Review, Patient Access, insurance companies, and other hospital partners to promote timely and accurate financial clearance and minimize barriers to patient care.

Under general supervision, the coordinator evaluates authorization and referral requirements, establishes appropriate workflow and follow-up priorities, coordinates the exchange of required information, monitors outstanding requests, and facilitates resolution of issues that may delay or prevent authorization or referral completion. The position ensures authorization and referral information is accurate, appropriately documented, communicated to affected stakeholders, and aligned with payer, regulatory, departmental, and organizational requirements.

The Authorization and Referral Coordinator Serves as a central resource and liaison for internal and external customers, including physician offices, providers, clinical departments, Case Management, Utilization Review, Patient Access, insurance companies, and other hospital partners, to promote timely and accurate financial clearance and minimize barriers to patient care.

PRINCIPAL DUTIES AND RESPONSIBILITIES

• Coordinates the overall authorization and referral workflow for assigned services, including scheduled and unscheduled services, ensuring requirements are identified, addressed, documented, and communicated within established timelines.
• Serves as a primary coordination point between hospital departments, physician offices, providers, payers, and other stakeholders regarding authorization, referral, pre-certification, notification, and related payer requirements.
• Reviews scheduled services and patient accounts to identify authorization, referral, pre-certification, notification, medical necessity, and other payer requirements and determines appropriate next steps.
• Coordinates with appropriate departments and physician offices to establish responsibility for obtaining required information and completing outstanding payer requirements.
• Reviews payer requirements and determines the appropriate payer-specific process, documentation, and follow-up needed to support authorization or referral completion.
• Coordinates submission of authorization, referral, pre-certification, and notification requests to insurance carriers and other payers, ensuring required documentation and supporting information are available and appropriately submitted.
• Reviews authorization determinations to ensure approved services, procedures, diagnoses, locations, providers, date ranges, units, and other applicable information correspond to the planned or rendered services.
• Coordinates the collection and completion of required physician referrals and supporting documentation and ensures referral information is appropriately recorded.
• Monitors assigned authorization and referral work queues, reports, task lists, pending requests, and other departmental workflows to prioritize outstanding items, identify barriers, and ensure timely progression and resolution.
• Establishes follow-up priorities based on scheduled service dates, payer turnaround times, clinical urgency, and other applicable departmental criteria.
• Follows up with insurance companies and other payers regarding pending, incomplete, or unresolved requests and coordinates next steps when additional information or action is required.
• Reviews authorization and referral information for completeness, accuracy, and consistency; identifies missing or conflicting information and coordinates appropriate correction or follow-up.
• Coordinates the exchange of clinical documentation and other supporting information between providers, physician offices, Case Management, Utilization Review, clinical departments, and payers.
• Communicates authorization and referral status, payer requirements, outstanding documentation, denials, limitations, and potential barriers to appropriate clinical, operational, and physician-office partners.
• Proactively identifies authorization or referral issues that may affect the scheduled date of service and coordinates with appropriate stakeholders regarding available options, including potential rescheduling when necessary and consistent with clinical and departmental processes.
• Coordinates inpatient authorization and notification requirements and facilitates timely communication with payers regarding admissions, continued stays, and other applicable requirements.
• Serves as a resource to Utilization Review, the House Supervisor, physician offices, Patient Access, and other stakeholders regarding payer-specific requirements related to inpatient versus outpatient status and authorization or notification processes.
• Reviews authorization denials and coordinates communication and follow-up with appropriate clinical, operational, and physician-office partners within established notification timelines.
• Coordinates appeals, reconsiderations, peer-to-peer requests, and additional clinical documentation requests, as assigned, by facilitating communication and information exchange between payers, providers, and appropriate hospital departments.
• Assists departments and stakeholders in understanding authorization and referral requirements, status, documentation needs, and other financial clearance barriers.
• Maintains working knowledge of third-party payer requirements, authorization guidelines, referral requirements, medical necessity criteria, insurance contracts, and payer-specific processes.
• Monitors team mailboxes, email inboxes, faxes, telephone calls, work queues, and other communication channels and prioritizes and coordinates responses to authorization and referral issues.
• Maintains close working relationships with Patient Access, Patient Financial Services, clinical departments, physician offices, Case Management, Utilization Review, and other hospital departments to promote effective communication and coordinated resolution of authorization and referral issues.
• Provides professional, efficient, respectful, and customer-focused service to patients, families, providers, physician office staff, payers, co-workers, and other stakeholders through in-person, telephone, and electronic communication.
• Utilizes established communication standards and scenario-specific call scripts when interacting with patients, providers, physician office staff, payers, and other stakeholders.
• Utilizes electronic systems and applications required to coordinate authorization and referral activities, including applicable electronic medical records, authorization and referral management, insurance verification, communication, document management, and scheduling systems.
• Ensure authorization and referral information is accurately and timely documented, including payer contacts, submission dates, reference numbers, authorization determinations, follow-up activity, outstanding requirements, and other applicable information.
• Identifies trends, recurring payer issues, workflow barriers, service-line concerns, and opportunities for process improvement and communicates findings and recommendations to leadership.
• Participate in the development and refinement of authorization and referral workflows, procedures, communication processes, and departmental standards.
• Assists with monitoring departmental performance, including authorization turnaround times, outstanding requests, denials, unresolved issues, and other applicable quality and operational measures.
• Assists with training and orientation of staff, as assigned, and serves as a resource regarding authorization and referral workflows, payer requirements, and departmental processes.
• Assists with departmental reports, audits, process improvement initiatives, payer-related projects, and special projects designed to improve financial clearance, workflow efficiency, communication, and patient access.
• Escalates complex, high-risk, unresolved, or time-sensitive authorization and referral issues to appropriate leadership or subject-matter resources.
• Maintains compliance with HIPAA, Bay Area Hospital policies and procedures, and applicable federal and state laws and regulations.
• Performs other duties as assigned.

SKILLS AND ABILITIES

• Demonstrates strong organizational, coordination, prioritization, and time-management skills with the ability to manage multiple workflows, stakeholders, deadlines, and competing priorities.
• Demonstrates the ability to coordinate work across multiple departments and external organizations while maintaining accountability for follow-up, communication, and resolution.
• Demonstrates strong analytical and problem-solving skills, including the ability to identify barriers, research payer requirements, evaluate options, and coordinate appropriate resolutions.
• Demonstrates strong attention to detail and accuracy when reviewing payer requirements, authorization determinations, referral documentation, and patient account information.
• Demonstrates effective verbal and written communication skills, including the ability to clearly communicate complex payer requirements and issues to diverse audiences.
• Demonstrates professional and effective interpersonal and customer service skills when communicating with internal and external customers, including patients, providers, physician office staff, insurance companies, internal departments, leadership, and other stakeholders.
• Demonstrates the ability to independently organize and coordinate work with minimal supervision and exercise sound judgment regarding priorities, escalation, and follow-up.
• Demonstrates the ability to recognize issues that may affect patient access, financial clearance, reimbursement, or the scheduled date of service and take appropriate action.
• Demonstrates the ability to facilitate resolution of issues through effective communication, collaboration, follow-up, and appropriate escalation.
• Demonstrates proficiency using personal computers, electronic medical records, payer websites, authorization and referral management systems, insurance verification systems, work queues, reporting tools, and other software applications applicable to the position.
• Demonstrates the ability to work collaboratively with multiple departments, providers, physician offices, insurance companies, and external healthcare organizations.
• Demonstrates the ability to identify workflow trends and opportunities for process improvement and communicate observations and recommendations to leadership.
• Maintains regular, consistent, and punctual attendance at the assigned work location.
• Demonstrates keyboarding proficiency of at least 25 words per minute.
• Demonstrates working knowledge of healthcare terminology, health insurance types, eligibility, benefits, authorization and referral requirements, medical necessity, payer processes, and healthcare revenue cycle workflows.

EDUCATION/CERTIFICATIONS/LICENSES/DEGREES

• High school diploma or equivalent required.
• Associate degree or higher education, or completion of relevant college coursework, preferred.
• Relevant healthcare revenue cycle, patient access, medical office, insurance, or authorization/referral certification preferred.

EXPERIENCE

• One (1) year of experience in healthcare Patient Access, Patient Financial Services, insurance verification, referral coordination, medical office operations, healthcare revenue cycle, customer service, or a related area required.
• Previous experience coordinating healthcare authorizations, referrals, pre-certifications, or payer requirements preferred.
• Previous experience working with health insurance companies, payer portals, electronic medical records, referral management systems, healthcare revenue cycle systems, or related applications preferred.
• Experience coordinating work across multiple departments, providers, physician offices, or external organizations preferred.

GENERAL INFORMATION

This is a non-union position.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, qualifications, or job skills required.

PHYSICAL/MENTAL/ENVIRONMENTAL REQUIREMENTS

• Requires extensive sitting with periodic standing and walking.
• May be required to lift and/or carry up to 20 pounds.
• Requires frequent use of a personal computer, telephone, and general office equipment.
• Requires adequate visual acuity and the ability to grasp, handle, and manipulate objects necessary to perform essential job functions.
• Requires the ability to communicate effectively and professionally through reading, writing, speaking, and telephone communication.
• Requires the ability to coordinate multiple workflows, prioritize competing demands, make decisions regarding follow-up and escalation, meet established deadlines, and maintain accuracy in a time-sensitive environment.
• Requires the ability to work effectively with frequent interruptions and changing priorities.
• May require occasional off-site travel.

Compensation Grade:

Compensation Grade Profile:

Bay Area Hospital is an Equal Opportunity Employer.

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