AUTHORIZATION SPECIALIST

Definition and Role

Under the direction of the Assistant Director of Revenue Cycle – Care Transition, the Authorization Specialist is responsible for obtaining and verifying insurance authorizations for patients receiving wound care services. This includes working closely with providers, insurance companies, and patients to ensure that services are authorized and reimbursable. The specialist ensures timely and accurate processing of pre-authorizations, re-authorizations, and medical necessity documentation to minimize denials and delays in patient care.

Job Responsibilities and Duties

• Obtain prior authorizations and re-authorizations for wound care services, including advanced dressings, negative pressure wound therapy (NPWT), debridement, biologics, Platelet Rich Plasma and hyperbaric oxygen therapy (HBOT).
• Confirm and verify insurance eligibility and benefits related to wound care treatment plans.
• Collaborate with physicians, nurses, and clinical staff to gather and submit required documentation for medical necessity and insurance approvals.
• Track and follow up on pending authorizations to ensure timely responses from payers.
• Communicate with insurance companies, third-party payers, and patients regarding coverage issues, denials, and requirements for appeals.
• Maintain accurate and up-to-date records in the electronic medical record (EMR) system and payer portals.
• Identify trends in payer denials and work with leadership to improve workflows and reduce authorization-related delays.
• Assist with insurance verification and coordination of benefits, as needed.
• Stay up to date on payer guidelines, CPT/HCPCS codes, and wound care-specific authorization criteria.
• Serve as a liaison between the clinical wound care team and the billing/revenue cycle department.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing this job the employee is frequently required to sit, talk and hear.
• The employee is occasionally required to walk, use hands and fingers to feel, handle, or operate objects, tools, or controls, and reach with hands and arms.
• The employee must occasionally lift and/or move objects weighing up to 25 pounds.
• Specific vision abilities required by this job include close vision and the ability to adjust and focus.
• Emotional/Psychological: Constant ability to make decisions and concentrate.

Qualifications

• High school diploma or equivalent required; Associate degree or higher preferred.
• Minimum of 2 years of experience in insurance verification or prior authorization in a healthcare setting.
• Experience with wound care, durable medical equipment (DME), or outpatient procedures preferred.
• Knowledge of ICD-10, CPT/HCPCS codes, and payer-specific requirements.
• Proficient with EMR systems and insurance portals.
• Strong communication, organization, and problem-solving skills.
• Ability to work independently in a fast-paced environment and handle confidential information with discretion.