Surgical Authorization Specialist

The Surgical Authorization Specialist is responsible for insurance verification, benefits review, and securing required pre-certifications, authorizations, and referrals prior to surgical services. This role plays a key part in the revenue cycle by ensuring timely approvals, accurate documentation, and clear communication with patients, payers, and clinical teams.

This position is on-site for the first 90 days for training, after which it becomes hybrid eligible based on performance and business needs.

Key Responsibilities

• Verify insurance eligibility and benefits prior to scheduled surgical services.
• Review, submit, and track surgical authorization and pre-certification requests.
• Communicate with insurance carriers via payer portals and phone to obtain approvals, authorizations, predeterminations and referrals as needed.
• Interpret payer medical policies and clinical guidelines to confirm medical necessity.
• Calculate and communicate estimated patient financial responsibility prior to surgery.
• Monitor authorization requests through final determination and follow up on pending cases.
• Collaborate with clinical staff, surgery schedulers, and revenue cycle teams to resolve authorization issues or denials.
• Support escalation cases, including coordination of peer-to-peer reviews when required.
• Accurately document authorization activity and payer communication in the EMR/EPM system.
• Respond to patient inquiries regarding insurance benefits, authorizations, and surgery-related costs.
• Maintain compliance with payer requirements, healthcare regulations, and internal workflows.
• Manage a high volume of work while maintaining accuracy, attention to detail, and excellent customer service.
• Perform other related duties as assigned.

Minimum Qualifications

• High School Diploma or equivalent.
• Minimum of 3 years of recent experience in surgical authorization, insurance verification, or healthcare revenue cycle.
• Proficiency in CPT, ICD-10, and HCPCS coding, including modifiers.
• Strong knowledge of insurance authorization processes and payer websites/portals.
• Ability to read and interpret medical records and Explanation of Benefits (EOBs).
• Strong organizational skills with the ability to manage multiple priorities and deadlines.
• Excellent verbal and written communication skills.
• Proficiency with Microsoft Office and electronic medical record (EMR/EPM) systems.
• Ability to work independently and collaboratively in a fast-paced, high-pressure environment.

Preferred Qualifications

• Clinical background.
• Prior experience in ENT specialty.
• Experience with eClinicalWorks Practice Management system.
• Experience working in a Central Business Office (CBO) environment.

Work Environment & Schedule

• On-site for the first 90 days for training, then hybrid work eligible based on role requirements and performance.
• Office environment with minimal noise during on-site work.
• Requires sitting, standing, reaching, and repetitive computer and phone use.
• Vision requirements include close vision, distance vision, and ability to adjust focus.
• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.