Prior Authorization and Referral Coordinator

Job Description

Job Description

West Cecil Health Center (WCHC) is seeking a dedicated Prior Authorization and Referral Coordinator to join our team at our location in Conowingo, Maryland.

WCHC is a thriving nonprofit, community health organization that provides comprehensive and collaborative patient centered healthcare services. Bilingual is a plus.

Position Summary:

The Prior Authorization & Referral Coordinator will be responsible for managing and facilitating the prior authorization and referral process for patients within the healthcare setting. This position ensures timely, accurate, and efficient processing of prior authorizations and referrals in accordance with insurance guidelines, organizational protocols, and regulatory requirements. The coordinator will work closely with healthcare providers, insurance companies, and patients, ensuring a seamless process that supports optimal care delivery.

WHY SHOULD YOU APPLY?

• Growth and Advancement Opportunities
• Company Sponsored Events
• Employee Engagement Committees
• WCHC offers a compressive benefit package including:

1. Medical, Dental, and Vision insurance
2. Health Reimbursement Arrangement
3. Employer paid Life and AD&D and Disability insurance
4. 401K with employer match
5. Generous Paid Time Off and Volunteer time
6. Paid Holidays
7. Education reimbursement

Key Responsibilities:

• Prior Authorization Management

  • Review and process requests for prior authorizations for medical procedures, medications, and services as required by insurance providers.

  • Liaise with insurance companies to obtain authorizations and address any issues or delays

  • Communicate authorization status to patients, healthcare providers, and other relevant parties

  • Track and maintain a comprehensive record of all prior authorizations and their outcomes

• Referral Management

  • Process patient referrals to specialists and additional services as required

  • Ensure that referrals are processed accurately and within required timelines

  • Communicate referral status to patients and providers, ensuring follow-through on all steps

• Documentation & Compliance

  • Maintain up-to-date, accurate documentation of all prior authorizations and referral activities in accordance with organizational protocols and HIPAA regulations

  • Ensure all activities are compliant with insurance policies, healthcare regulations, and internal quality standards

• Collaboration & Communication

  • Serve as a liaison between patients, healthcare providers, and insurance companies to resolve issues related to prior authorizations and referrals

  • Work closely with the Quality Manager and other team members to implement improvements in prior authorization and referral processes.

  • Support the quality movement initiatives by identifying trends and issues related to prior authorizations and referrals

• Patient Education & Support

  • Educate patients on the prior authorization and referral process, including explaining necessary documentation, timelines, and next steps.

  • Address patient concerns related to delays or issues with authorization and referrals, providing updates and solutions in a compassionate and professional manner

• Data Tracking & Reporting

  • Assist in tracking and reporting metrics related to prior authorizations and referrals, supporting the development of process improvements

  • Prepare reports for the Quality Manager to identify areas for process optimization and enhance patient care.

Additional Duties:

• Bilingual employees: Provide communication and translation assistance to patients within the scope of the role.

• Perform other assigned duties as needed.

Qualifications & Experience

We are seeking a highly motivated and skilled individual who aligns with the mission of West Cecil Health Center. The ideal candidate will demonstrate proficiency in the following areas:

Essential Skills:

• Strong commitment to the mission of West Cecil Health Center

• Exceptional organizational skills with the ability to multitask, prioritize, and manage workload effectively under pressure

• Attention to detail

• Excellent guest relations skills, fostering a positive and supportive environment

• Strong communication skills, both verbal and written, with the ability to interact professionally with patients, providers, and insurance companies

• Ability to complete tasks efficiently and independently, maintaining sustained focus and concentration for detailed work.

• Proficiency with computer systems and medical software; familiarity with electronic health records (EHR) and Microsoft Products is advantageous

• Strong problem-solving skills with the ability to navigate complex insurance and healthcare systems

• Understanding of HIPAA laws regarding patient confidentiality

Required Education & Experience

• High school diploma or equivalent, required

• Associate’s degree in healthcare administration or related field, preferred

• Completion of an accredited Medical Assistant or CNA program, preferred

• Federally Qualified Health Center experience preferred

• 3 years experience in prior authorization and referrals or a similar role within a healthcare setting

• Knowledge of insurance plans, benefit coordination, prior authorization processes, and medical terminology is essential

Reasonable Accommodations Statement

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable Accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Supervisory Responsibility

This position has no supervisory responsibilities.

Position Type and Expected Hours of Work

This may be a full-time. Days and hours of work will be scheduled in accordance with operational needs.

Physical & Environmental Requirements

To successfully perform this role, the Prior Auth & Referral Coordinator must possess the following abilities:

• Sufficient capability to fulfill job responsibilities.

• Standing, walking, sitting: Ability to stand, walk, and/or sit at a desk/workstation for prolonged periods (typically 8-12 hours per shift).

• Lifting, carrying, pushing, pulling: Ability to lift, carry, push or pull up to: 20 pounds (examples: medical equipment, supplies, patient files).

• Reaching: Capacity to reach (choose overhead and/or at or below shoulder level)

• Keyboarding: Entering text or data into a computer or other machine by means of a traditional keyboard.

• Gross Manipulation: Seizing, holding, grasping, turning, or otherwise working with the hand(s). It is often present when lifting involves the hands. Note: Fingers are involved only to the extent that they are an extension of the hand to hold or operate a tool such as tin snips or scissors.

• Fine Manipulation: Touching, picking, pinching, or otherwise working primarily with fingers to execute tasks such as answering phones, typing, transporting, and filing charts.

• Speaking: Ability to express or exchange ideas by means of the spoken word to impart oral information to clients or the public and to convey detailed spoken instructions to other workers accurately, loudly, or quickly.

• Hearing Requirements: The ability to hear, understand, and distinguish speech and/or other sounds (e.g., machinery alarms, medical codes or alarms). Including in-person speech, over the telephone, and/or using equipment

• Visual Acuity: sufficient to clearly see and distinguish small objects, including while using a computer, as well as to recognize individuals and features at a distance

Location & Travel

This position is located in West Cecil Health Center and/or its qualified subsidiaries. Regular local travel between sites may be warranted.

Other Duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

WCHC is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to age, race, color, national origin, ancestry, religion, sex, sexual orientation, pregnancy, marital status, credit history, physical or mental disability, genetic information, veteran status, uniformed service member status, or any other characteristic protected by law.