Physician Authorization/Referral Specialist I

Join our team as a Physician Authorization/Referral Specialist, where you'll play a vital role in ensuring patients receive timely, coordinated care.

The Specialist is responsible for obtaining and processing elective, urgent, and emergent referrals and authorizations for a wide range of outpatient services, including cardiology, audiology, lab testing, genetic testing, and certain medications. They verify insurance eligibility and benefits, calculate and communicate patient cost estimates, and ensure copay requirements and approvals are completed before services occur.

This role works closely with insurance companies, primary care providers, partner hospitals, and internal departments to ensure accurate information, timely claim processing, and seamless patient support. The Specialist uses daily reports and work queues to follow up on pending cases, participates in department huddles, and helps resolve issues that could affect reimbursement. They are also expected to deliver excellent customer service, support Medicaid enrollment processes, use EPIC effectively, and assist with training new team members.

Responsibilities:

1.Ensure timely notification and request for authorization/referrals is handled in accordance with departmental policy and payor requirements.
2. Maintaining confidentiality, verify patient demographics, insurance eligibility, benefits, and financial responsibility.
3. Ability of request/obtain authorizations/referrals for assigned specialties and be able to cover for most specialties.
4. Communicate effectively, timely and professionally in writing and verbally
5. Contact and interview families in person or by phone contact to obtain necessary information and assist them with insurance issues that may be preventing authorization/referrals.
6. Clearly document all communications and contacts with payors and families in standardized documentation requirements including proper format
7. Consistently demonstrates excellent, empathetic and knowledgeable customer service skills to internal and external customers
8. Is aware and adheres to all State and Federal Regulations including, but not limited to: EMTALA, HIPAA, and the Joint Commission
9. Ability to review workflows and suggest improvements in specialty areas
10. Ability to work independently, prioritize workload and assist other associates as required.
11. Build and maintain professional, cooperative relationships with all departments that have direct or indirect impact on obtaining authorizations.
12. Prepare estimates for scheduled services. Must interpret patient's benefits correctly for accurate estimates.
13. Work with partner hospitals for claim submission and registration accuracy.

Qualifications:

• Referral/authorization work experience required (minimum one year experience)
• High School diploma required

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Learn more at Nemours.org .