Referral & Authorization Care Coordinator

Referral and Authorization Coordinator

Reports To: Manager, Care Operations
Schedule: Monday- Friday 12-8pm EST
Employment Type: Full-Time

Role Overview

As our Care Coordinator specializing in Prior Authorizations & Referrals, you will manage back-office responsibilities including referral management, prior authorizations, specialty pharmacy & infusions, and medical records to help deliver and implement clinical strategies and support member care coordination in collaboration with a multidisciplinary clinical team. You will use a high level of attention to detail, organization, and communication skills to obtain, manage, and follow up on member referrals and prior authorizations to ensure key care plan goals are met.

What You'll Do: Key Responsibilities

• Collaborate with a multidisciplinary team of care providers (including MDs, NPs, RDs, Behavioral Health Providers, and Health Coaches) to provide a whole-person approach to member care.
• Coordinate, track, and communicate patient referrals, prior authorizations, and medical records to promote team awareness and patient safety.
• Provide complete and accurate registration of referrals and authorizations, including patient demographics, insurance information, and clinical documentation to external providers and specialty pharmacies.
• Offer proficient knowledge of referrals, insurance requirements, and the prior authorization process to internal and external resources, eliminating barriers to care and following up on progress toward key goals.
• Apply knowledge of CPT and ICD-10 codes to obtain authorizations in a timely manner while demonstrating understanding of payer medical policy guidelines.
• Initiate appeals for denied authorizations and maintain close follow-up to ensure positive member outcomes.
• Engage in external coordination of pharmacy support services to ensure members receive all necessary support throughout the prior authorization process.
• Assist members in accessing services, providing personalized customer service while maintaining close communication with the care coordination team.
• Manage key reports and track relevant data to identify successes and drive refinements in operational processes.

What We're Looking For: Qualifications & Requirements

Required

• Minimum of 2-3 years experience in healthcare coordination, care, or case management within a remote digital healthcare space
• Completed degree in a health and science related field (biology, psychology, health science, nutrition, nursing, etc.).
• Fluent in healthcare terminology with a working understanding of clinical concepts.
• Background knowledge navigating health insurance plans and coverage, with ability to provide benefits breakdown analysis to consumers.
• Comfortable and competent with common administrative technologies (Zoom, Slack, Office or equivalent), charting electronically in EMR/EHR systems

Preferred

• Experience working in telehealth or a digital health environment.
• Strong critical thinking skills with ability to triage accurately and escalate appropriately.
• Experience in a high-growth startup or mission-driven healthcare organization.