Patient Auth and Referral Specialist I

Job Description Summary

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Supports CareMore's integrated care delivery model by processing routine prior authorizations and specialty referrals that ensure members receive timely, medically appropriate care across the continuum. Performs insurance verification, authorization processing, referral coordination, and documentation while partnering with CareMore clinical teams, providers, and health plans to promote seamless access to services.
Patient Authorizations and Referrals Specialist I performs routine, well-defined work under close supervision while building foundational knowledge of CareMore workflows, utilization management requirements, and value-based care principles. Work follows established policies, payer guidelines, and CareMore operating procedures, with decisions based on defined criteria and reviewed by experienced team members.

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How will you make an impact & Requirements

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KEY RESPONSIBILITIES

• Process incoming prior authorization and specialty referral requests by verifying member eligibility, benefit coverage, provider participation, and required clinical documentation in accordance with CareMore and health plan requirements.
• Review requests for completeness and ensure supporting clinical information meets payer and CareMore medical necessity guidelines before submission.
• Enter and maintain accurate authorization, referral, and member information within CareMore's electronic health record (EHR), referral management, and utilization management systems.
• Coordinate with CareMore providers, care managers, specialists, and external provider offices to obtain missing documentation, schedule services, and facilitate timely authorization decisions.
• Communicate authorization and referral status updates to members, caregivers, providers, and internal care teams while maintaining excellent customer service and member-centered communication.
• Monitor pending authorizations and referrals to ensure compliance with CareMore turnaround time standards, escalating delayed or complex cases to senior team members or leadership as appropriate.
• Maintain complete and accurate documentation of all authorization activities, communications, and outcomes in accordance with CareMore policies, CMS regulations, HIPAA requirements, and health plan contractual obligations.
• Support continuity of care by helping ensure members receive appropriate access to specialty care, diagnostic testing, outpatient services, and community resources.
• Participate in quality improvement initiatives and departmental workflows designed to improve member access, reduce authorization delays, and support CareMore's value-based care objectives.

QUALIFICATIONS

• High school diploma or equivalent required.
• 0–2 years of experience in healthcare administration, managed care, medical office operations, insurance verification, patient access, referrals, or prior authorizations.
• Basic understanding of managed care, Medicare Advantage, Medicaid, or commercial insurance authorization processes preferred.
• Familiarity with electronic health records (EHR), referral management systems, and Microsoft Office applications preferred.
• Strong attention to detail with the ability to accurately follow established workflows and documentation requirements.
• Effective written and verbal communication skills with a commitment to delivering compassionate, member-centered service.
• Ability to prioritize multiple tasks and work efficiently in a fast-paced, team-oriented healthcare environment.
• Knowledge of HIPAA privacy regulations and commitment to maintaining confidentiality.
• Ability to collaborate effectively with interdisciplinary care teams while working under close supervision.

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Compensation Range:

$19.80

to

$29.70

 

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.