AUTHORIZATION REPRESENTATIVE JOB DESCRIPTION

Tracking down approvals before a patient reaches the operating table - that is the job. An Authorization Representative manages the insurance authorization process for clinical services ranging from surgical procedures and radiology to infusions and laboratory testing, ensuring that coverage is confirmed before care is delivered. In healthcare revenue cycle operations, this function sits between clinical scheduling and payer reimbursement, requiring fluency in Medicaid and Managed Care Organization requirements that neither billing nor front-desk staff fully own. Errors here translate directly into claim denials.

As the Authorization Representative, you obtain, verify, and track insurance authorizations across inpatient and outpatient service lines, keeping payer approvals aligned with clinical scheduling to protect reimbursement integrity. You work within the Revenue Cycle Management department, collaborating daily with Case Managers, attending physicians, APPs, and insurance payer representatives to resolve authorization discrepancies before they affect patient care or billing outcomes.

Career Impact: Hands-on experience navigating Medicaid, MCO payer requirements, and ICD-10/CPT coding builds a durable credential set recognized across hospital systems, specialty clinics, and health plan organizations.

Business Impact: Authorizations that lapse or misfire delay procedures and trigger claim denials - your work as Authorization Representative is what keeps the revenue cycle moving for patients who need timely care.

Growth Opportunity: The operational and payer knowledge this role develops is the direct foundation for advancement into insurance verification leadership, patient access management, or revenue cycle analyst roles.

• Obtain prior and same-day authorizations for surgical, endoscopic, radiology, laboratory, and infusion services within established clinical timelines.
• Review insurance verification records and complete the authorization process within payer-specific time frames to prevent coverage gaps.
• Monitor active authorizations for expiration and secure renewals before lapse to protect uninterrupted patient service delivery.
• Identify over- and under-authorization discrepancies and coordinate with Service Coordinators and Managed Care Organizations to correct payer records.
• Coordinate peer-to-peer authorization reviews between ordering specialists and insurance medical directors as required by payer policy.
• Collaborate with Case Managers and clinical staff on STAT and routine authorization needs, adjusting schedules to align with confirmed coverage.
• Document all authorization activity, payer communications, and expiration tracking accurately to support downstream billing and compliance review.
• Alert supervisors and billing staff promptly when required documents are missing, late, or at risk of affecting claim submission deadlines.

• High School diploma or equivalent; associate degree in health information, medical administration, or related field preferred.
• 2 or more years of insurance verification or authorization experience in a healthcare or clinical setting, with exposure to payer portal workflows.
• Knowledge of Medicaid and Managed Care Organization payer structures, including authorization submission and appeals processes.
• Proficiency in medical terminology, ICD-10 diagnosis coding, and CPT procedure coding relevant to surgical, radiology, and infusion services.
• Demonstrated data entry accuracy with ability to type a minimum of 30 wpm and operate 10-key by touch.
• Strong organizational skills with the ability to manage multiple active authorizations, track expiration dates, and meet strict payer deadlines concurrently.
• Clear written and verbal communication skills to liaise professionally with physicians, insurance representatives, and internal clinical staff.

• Prior experience working with electronic medical record and practice management systems in a hospital or multi-specialty clinic environment.
• Familiarity with peer-to-peer review processes and direct engagement with insurance medical directors on complex or STAT authorization cases.
• Background in revenue cycle operations, including billing submission workflows or Explanation of Benefits interpretation.
• Experience handling authorization for a high-volume, mixed-modality service line spanning both inpatient and outpatient procedures.

• Authorization turnaround time, measured against payer-required submission windows for routine and STAT cases.
• Authorization expiration rate, tracking the percentage of approvals that lapse before service delivery.
• Claim denial rate attributable to missing or incorrect prior authorization documentation.
• Discrepancy resolution rate, reflecting how quickly over- and under-authorization issues are corrected with payer or care coordinator.
• Worklist completion rate, measuring daily throughput of assigned authorization tasks against department productivity standards.
• Typical tools: EHR and EPM platforms (commonly EMR systems); payer portals (commonly MCO web portals); authorization management systems (commonly Sandata SAM).

• Base Salary Range: $38,000 to $52,000 per year, depending on experience and geography.
• Bonus: Merit-based annual bonus, typically 3 to 5 percent of base salary.
• Equity: Not typically offered at this level in healthcare operations roles.
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by system size.
• PTO: 10 to 15 days annually, plus standard federal holidays.
• Common Perks: Tuition reimbursement for medical billing or coding certification; employee assistance programs.

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment contingent on successful completion of a background check and, where applicable, drug screening consistent with healthcare facility requirements. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations are available to applicants and employees with disabilities upon request. Candidates must be authorized to work in the United States.

The Authorization Representative owns the end-to-end insurance authorization workflow for the Revenue Cycle Management Department, obtaining approvals from Managed Care Organizations, tracking expiration dates, and resolving over/under authorization discrepancies to protect billing integrity. Reporting to the Authorization Supervisor, this role collaborates with Case Managers and Service Coordinators to ensure payer approvals align with scheduled patient services.

Key Responsibilities

• Obtain authorizations from HHAeXchange and enter information into Sandata SAM system.
• Identify over/under authorizations and contact Service Coordinators and/or Managed Care Organizations to confirm or correct as needed.
• Work with Case Managers to adjust the schedule to properly utilize the authorization.
• Utilize payor portals, HHAeXchange, MCO provider lines and email to communicate and resolve authorization issues.
• Identify Managed Care Organization and authorization changes as they are occurring, correct and modify master profiles as necessary.
• Keep track of all authorizations and expiration dates and obtain new authorizations before expiration.
• Alert the Administrator or Manager regarding late or missing documents required for billing.
• Produce reports as needed.
• Perform administrative duties such as sorting, scanning, filing, and emailing records.
• Perform other job-related duties as assigned.

Required Qualifications

• 1–2 years of experience in data entry, record keeping, or similar experience in the healthcare field.
• Knowledge of Medicaid/Managed Care Organization (MCO), insurance verification, and authorization management.
• Intermediate to advanced computer skills including Microsoft Office (Word, Excel); knowledge of Sandata, MCO portals, HHAeXchange, and Waystar (Zirmed) preferred.
• Analytic and persistent; able to get to the root of problems; strong attention to detail; maintains confidentiality; self-motivated and reliable.
• Demonstrates excellent communication and customer service skills under duress and in a fast-paced environment.
• Ability to function as a positive team member.
• Ability to sit for long periods of time, use a PC keyboard, and deal with stress and conflict appropriately.
• Reasonable accommodations may be made for individuals with disabilities.

Embedded within the Benefit Investigation team, the Prior Authorization Representative delivers prior authorization support by contacting insurance companies and physician offices on behalf of clients and patients, including completing SMN forms and managing pre-determination medical requests to validate medical necessity. Working closely with ordering physicians, insurance representatives, and internal case teams, this role ensures worklist tasks are completed within process standards to support timely coverage decisions.

Core Functions

• Review case and insurance coverage information to customize the content of the call to the insurance company or physician's office.
• Provide insurance company representatives with an overview of the services in which coverage is being requested in the attempt to obtain prior authorization.
• Answer questions regarding the reimbursement process and direct testing specific and treatment questions.
• Complete SMN form based on client or insurance requirements and fax to the ordering physician's office for completion.
• Follow up with the insurance company or physician's office based on pending documentation or approval.
• Meet benefit investigation process standards by completing assigned worklist tasks in a timely manner and reporting to management when assistance is needed.
• Participate in team meetings by sharing the details of cases worked.

Qualifications & Experience

• High School diploma or GED.
• Minimum of two years of customer service experience.
• Knowledge of health insurance terminology and billing process or equivalent.
• Proficient in Microsoft Excel and Word.
• Proficient and attentive to detail; possesses superior customer service skills.
• Excellent written and verbal communication skills; ability to maintain confidentiality.
• Ability to multitask, establish priorities, and work independently.

Reporting to department leadership, the Refill Authorization Representative processes refill and prior authorization requests for all Primary Care providers from a centralized location, communicating patient concerns to physicians and registered nurses verbally and in writing. Partnering with patients, pharmacies, and clinical staff, this role ensures accurate EHR documentation and timely scheduling support that keeps care coordination running without interruption.

Primary Duties

• Communicate patient requests and concerns to physician or registered nurse verbally and in writing; process refill and prior authorization requests in a centralized location for all Primary Care providers under general supervision.
• Prepare refill and prior authorization requests for review by the provider as directed by department protocols.
• Schedule appointments if necessary and arrange lab tests prescribed by physician or registered nurse.
• Enter and gather patient information in the EHR to process refill and prior authorization requests.
• Document pertinent information in the EHR and communicate with patients via email, mail, or phone as directed by department protocols.
• Foster positive interpersonal relationships with fellow employees, physicians, and patients.

Education & Experience

• Successful completion of a Washington State Board of Pharmacy approved Pharmacy Technician training program or a state-approved accredited Medical Assistant program.
• Current certification from WA State Department of Health as a Medical Assistant-Certified or WA State Pharmacy Technician License.
• Minimum of two (2) to three (3) years of experience in healthcare including understanding of health plan related operations; prior experience as a Pharmacy Technician or Medical Assistant.
• Previous exposure to a call center environment and/or customer service-oriented job experience.
• Ability to foster positive interpersonal relationships with fellow employees, physicians, and patients.

Sitting at the intersection of clinical operations and payer relations, the Authorization Representative leads insurance authorization for surgical, endoscopic, radiology, infusion, and laboratory services, coordinating peer-to-peer reviews between specialists and insurance companies to keep procedures on schedule. Operating across hospital departments and working alongside doctors, APPs, and case teams, this role delivers accurate, timely payer approvals including same-day and STAT authorizations.

Duties

• Obtain and work with Hospital Departments to obtain authorizations in a timely manner for endoscopic procedures, surgical procedures, radiology, laboratory testing, infusions, and visits.
• Review insurance verification and complete the authorization process within established time frames.
• Accurately enter data into software programs.
• Receive coverage authorization and work diligently to meet established timelines, including same-day procedures as required.
• Work closely with doctors, APPs, and team members to accomplish authorization and verification for both routine and STAT orders.
• Routinely arrange and oversee peer-to-peer authorizations between specialists and insurance companies.

Skills & Qualifications

• High School diploma or equivalent.
• 3–5 years of insurance verification experience plus 1–2 years of authorization experience, OR 1–2 years of healthcare experience in a clinical setting.
• Knowledge of payer requirements for authorization and billing.
• Knowledge of ICD-10 and CPT coding; proficiency in medical terminology.
• Proficiency in EMR and EPM; demonstrated computer experience using word processing and data entry software.
• Ability to type 30 wpm and operate 10-key by touch.
• Demonstrated effective communication, interpersonal, organizational, and problem-solving skills.
• Attention to detail; ability to adhere to strict timelines and multitask; previous customer service experience.

A key member of the warranty claims team, the Prior Authorization Representative builds efficiency in pre-approval and warranty claim processing by validating repair documentation, coding, and diagnostic routines in accordance with manufacturer policy. Collaborating across dealer networks, client personnel, and internal team leaders, this role supports accurate claim payment decisions and delivers reporting tools that improve team-wide process performance.

Functions

• Review and process pre-approvals and warranty claims in accordance with manufacturer policy and procedures.
• Ensure quality standards and customer satisfaction goals are met or exceeded through daily management and support from the Lead Representative and Supervisor.
• Liaise with client personnel at all levels including dealers, customers, and internal teams.
• Pre-approve warranty repair requests and ensure approved diagnostic routines are followed with proper documentation.
• Process repair claims requiring review for payment to dealer and validate claims coding for proper causal part, labor op codes, and parts.
• Assist with dealer phone calls and respond to dealer email inquiries; send corrective action to team leaders and individuals.
• Utilize and develop Excel worksheets and templates to increase efficiency; create PowerPoint presentations for department meetings.

Requirements

• Minimum 0–1 years of experience in an automotive-related field.
• Minimum 1–2 years of experience with Microsoft Office including MS Excel formulas and macros and creating reports; experience creating PowerPoint presentations.
• Experience in a customer service environment a plus.
• Excellent oral and written communication skills.
• Excellent problem-solving skills.
• Reports to Group Leader/Team Leader/Project Management.
• Liaises with all company personnel internally and with customers, dealerships, and specialist warranty and technical data sources externally.

Accurate prior authorization processing for injured workers depends on the Pharmacy Prior Authorization Representative, who handles inbound and outbound contacts from providers, adjusters, and pharmacies while resolving eligibility issues, claim discrepancies, and escalations within performance agreement guidelines. Based within a multi-channel contact center environment, this role maintains complete documentation of all inquiries and works across operational departments to meet productivity standards and regulatory requirements.

Accountabilities

• Handle inbound and outbound calls, chats, emails, and interactive memos from injured workers, providers, adjusters, pharmacies, and internal/external clients.
• Execute tasks according to Standard Operating Procedures, Client Requirements, and Regulatory Requirements.
• Support pharmacies, providers, and internal/external clients regarding inquiries and issues related to Prior Authorization eligibility, rejections, and authorizations.
• Maintain productivity standards, quality assurance, and performance guarantees.
• Work with other operational departments to research and resolve mail order and retail pharmacy claims issues and respond within performance agreement guidelines.
• Maintain accurate and complete documentation of all inquiries and resulting actions.
• Identify and escalate concerns from patients, pharmacies, or clients so that corrective action can be pursued in a timely manner.
• Adhere to good housekeeping techniques and quality and production standards while complying with all applicable company, state, and federal safety requirements.
• Perform other duties as assigned.

Experience & Qualifications

• High School diploma or GED required.
• 1 year of relevant experience preferred.
• General PC knowledge including Microsoft Office and Internet.
• Excellent verbal and written communication skills.
• Ability to handle challenging customers professionally.
• Ability to adapt in a dynamic work environment.
• Learns quickly, solves problems, and makes decisions
• Willingness to work a flexible schedule for peak call and claims management times.