Verification/Authorization Specialist

Job Title: Verification/Authorization Specialist

Location: Performance Ortho Corporate Office (Bridgewater, NJ)

Employment Type: Full-time, Hybrid 2 days remote

Schedule: Monday – Friday

About Us

Performance Ortho is a leading provider of comprehensive orthopedic and outpatient care in New Jersey. With four clinic locations, an Ambulatory Surgery Center, and our corporate headquarters in Bridgewater, we’re celebrating 25 years of growth and excellence. Our holistic approach includes a wide array of services—Chiropractic, Physical Therapy, Acupuncture, Occupational Therapy, and Orthopedic Surgery—all aimed at delivering the highest quality of patient care. We pride ourselves on fostering a collaborative, supportive work environment where our team members are empowered to thrive and grow.

Job Overview

The Verification/Authorization Specialist is responsible for conducting detailed verification of patient eligibility and benefits, as well as securing required authorizations for services across government, commercial, and third-party payers. This role ensures accurate and timely eligibility and authorization determinations while adhering to compliance regulations. The specialist will collaborate with internal teams, external vendors, and insurance providers to resolve discrepancies, streamline processes, and maintain data integrity.

A strong understanding of Medicare, Medicare Advantage, private insurance plans, and other third-party payers is essential for success in this role.

Key Responsibilities

Eligibility & Verification

• Conduct detailed reviews of patient insurance coverage, supporting documents, and eligibility criteria.
• Verify patient insurance and benefit information for scheduled services, including diagnostics, therapies, and surgeries.
• Process eligibility determinations in accordance with company policies and payer guidelines.

Authorizations

• Obtain pre-authorizations and referrals as required by insurance carriers.
• Communicate with insurance representatives to ensure timely approval of procedures and services.
• Track and follow up on pending authorizations to prevent delays in care.

Compliance & Quality Assurance

• Ensure all verification and authorization activities align with company standards and regulatory requirements.
• Conduct audits and quality checks to maintain accuracy and minimize errors.
• Stay updated on payer policy changes and industry best practices.

Case Management & Collaboration

• Manage complex cases, including appeals, escalations, and exceptions.
• Collaborate with internal departments—billing, scheduling, and clinical teams—to resolve insurance-related issues.
• Provide guidance and support to junior staff as needed.

Documentation & Reporting

• Maintain accurate and up-to-date records in EHR and billing systems.
• Prepare reports and summaries on verification and authorization trends.
• Ensure compliance with HIPAA and internal confidentiality standards.

Communication & Patient Support

• Respond to inquiries from patients, providers, and other stakeholders.
• Clearly and professionally explain insurance coverage, eligibility status, and authorization outcomes.
• Support the development of internal communication materials and policy updates.

Preferred Candidate Attributes

• Exceptional attention to detail and accuracy
• Strong analytical and problem-solving skills
• Excellent communication and customer service abilities
• Ability to handle confidential information with discretion
• Team-oriented mindset with a proactive, solutions-driven approach
• Capable of managing multiple tasks and meeting deadlines in a fast-paced environment

Qualifications

• High school diploma or equivalent; Associate degree in healthcare administration or related field preferred
• Minimum of 2 years of experience in verification, authorization, eligibility determination, or a related healthcare role
• Familiarity with orthopedic billing codes, payer requirements, and insurance policies
• Knowledge of EHR systems and billing software (eClinicalWorks experience preferred)
• Proficiency in Microsoft Office Suite, especially Excel
• Strong communication skills, both written and verbal
• Ability to work independently and collaboratively within a team
• Must be able to work onsite in Somerset County, NJ