Prior Authorization/Referral Coordinator

Job Summary:

The Prior Authorization/Referral Coordinator works as a patient advocate and obtains prior authorizations for medical staff. Prior Authorizations include medical tests, procedures and/or medications. The prior authorizations are based on benefit plan design, patient specifics and clinical criteria. They will also ensure the effective management of all incoming and outgoing referrals and appointments for tests and/or procedures.

Performance Requirements:


  1. Sound knowledge of computers and software programs
  2. Basic understanding of medical terminology
  3. Familiar with medications, procedures and medical tests
  4. Understand Current HIPAA guidelines


  1. Have outstanding customer service skills even when under pressure
  2. Must possess good organizational skills
  3. Must be detail oriented while working on daily assigned tasks
  4. Must be a self-starter, ensuring daily duties are completed without constant supervision


  1. Must possess the ability to work well in a team environment
  2. Must have the ability to type a minimum of 35 WPM
  3. Must have the ability to work well under pressure
  4. Must have the ability to use discretion while maintaining patient confidentiality
  5. Must have good communication skills and be caring towards patients

Major Duties and Accountabilities:

  1. Handles inbound telephone and written inquiries from providers and staff regarding prior authorization by screening and reviewing requests based on benefit plan design, client specifics and clinical criteria.
  2. Provides information to patients, participants, pharmacists and doctors regarding participant’s benefit coverage.
  3. Facilitates resolution of prior authorization issues and pro-actively addresses researches and resolves issues while maintaining accurate and complete documentation of all inquiries.
  4. Obtains prior authorization for non-formulary medications.
  5. Assists the patients in obtaining appointments with specialists and acquiring special medical procedures.
  6. Assists in obtaining appointments for hospital follow-ups.
  7. Maintains ongoing tracking and appropriate documentation on referrals.
  8. Communicates professionally and respectfully to Insurance companies acting as a patient advocate and representing the clinic professionally.
  9. Communicates with clinical staff on any issues or need for further follow up.
  10. Contacts the patients regarding any pending referrals, and or diagnostic testing.
  11. Faithfully documents and retains all communication regarding the referral/authorization process.
  12. Works collaboratively with other associates and managers to ensure that best practices are shared.
  13. Maintains knowledge of resource materials such as medical dictionary, policy/procedure manual, employee handbooks, and organizational chart.
  14. Complies with policy and procedure manual of the clinic.
  15. Provides calm, reassuring atmosphere and communicates effectively with patients, staff, physicians, and other guests.
  16. Performs other related duties as assigned.
  17. Performs procedures according to the LMC policies and procedures as noted on skills check list/competency.
  18. Other jobs as assigned.

Position Competencies:

  1. Guest Relations: Demonstrates the highest standards for friendly, courteous and caring interaction with patients, physicians, guests, and fellow employees.
  2. Communication: Demonstrates ability to accept and understand instructions, expresses self clearly and concisely.
  3. Attendance/Punctuality: Is seldom tardy and or absent, Attends mandatory in-service programs and/or committees as assigned.
  4. Adaptability/Flexibility: Demonstrates the ability to cope with pressure, grasp new ideas, methods, and adjust responses to meet the changing work environment.
  5. Confidentiality: Assures patient and clinic confidentiality. Complies with HIPAA guidelines regarding patient confidentiality and protected health information.
  6. Independence/initiative: Demonstrates reliability, follow-through, ability to work with minimum supervision, desire and ability to accept additional responsibility.
  7. Judgment contacts: Makes sound and timely decisions regarding one’s work, personal appearance, and demeanor.

Job Qualifications:

Equipment operated: standard office equipment including computers, faxes, copiers, printers, telephones, etc.

Education/Experience:  High school diploma, G.E.D., or equivalent work experience. Certified Medical Assistant or one year of experience working in a medical facility is preferred.  Ability to effectively communicate and follow oral and written instruction.

Physical: Climbing, stooping, kneeling, crouching, reaching, handling, pushing, fingering, feeling with both hands, twisting back, reaching above, at or below shoulder level, eye/hand/foot coordination.  Will stand and walk 70-80% of the time. Employee will sit 20-30% of the time and will use physical strength of hands, fingers, arms, legs to move patients or equipment.