Authorizations Representative Lead

Rewarding career. Competitive salary. Outstanding benefits.

The Authorization Lead serves as both a working authorizations representative and team lead within Patient Financial Services. This position is responsible for completing insurance verification, obtaining prior authorizations, and ensuring compliance with payer requirements for specialty and hospital services at WHMC. In addition to managing their own workload, the Lead provides guidance, training, and workflow oversight for referral and authorization staff. The role functions as an Epic superuser, supports process improvement initiatives, and collaborates closely with clinical departments, scheduling, and the business office to minimize denials, enhance patient access, and optimize reimbursement.

STANDARD EXPECTATIONS

• Promotes a Positive Working Environment
  • Conducts oneself in line with organization’s mission, values and standards of behavior.
  • Consistently adheres to organizational policy.
  • Supports and maintains a culture of safety and quality.
  • Participates in committees as assigned.
• Communicates Effectively
  • Builds relationships and works collaboratively with other staff.
  • Provides timely operational updates to supervisor.
  • Responds to communications in a timely manner.
• Performs Duties Efficiently and Effectively
  • Assists in development of department schedule and other assigned staffing needs.
  • Serves as preceptor for new staff.
  • Provides guidance and education for existing staff.
  • Assists in identifying department process improvements. 
  • Provides guidance to others in same position.
  • Functions as EHR superuser.
  • Acts in compliance with applicable federal, state, and local regulations.
  • Performs other duties as assigned.

DUTIES & RESPONSIBILITIES

Authorization & Denials

• Enters authorization information into the patient accounting system, including effective dates, authorized visits, patient information, billing information, and other authorization requirements.
• Ensures authorization has not expired for the scheduled patient visits.
• Follows proper patient/beneficiary notice procedures for potential non-coverage.
• Communicates authorization information to appropriate staff as needed.
• Obtains authorizations from insurance companies/physicians/medical benefits Management Company.
• Coordinates with billers regarding denials.
• Researches denials and facilitates retro-authorization or appeals.

Denials Prevention & Resolution

• Reviews authorization-related denials and coordinates corrective actions with staff and departments.
• Works with providers and schedulers to prevent denials (e.g., CPT/diagnosis mismatches, missing authorizations).
• Tracks and reports denial trends, providing recommendations to leadership.

Process Improvement & Compliance

• Identifies workflow gaps and implements process improvements to streamline referral and authorization functions.
• Ensures compliance with CMS, Medicaid, Medicare Advantage, and commercial payer regulations.
• Collaborates with Revenue Cycle leadership to support organizational goals (e.g., reducing denial rates, improving cash flow).

Referral & Authorization Lead

• Reviews daily work queues to ensure timely completion of referrals and prior authorizations.
• Monitors scheduled and unscheduled services to confirm payer requirements are met before patient care.
• Ensures urgent and same-day authorization requests are prioritized and completed efficiently.
• Provides expertise to staff on payer-specific rules, medical necessity, and documentation requirements.
• Trains, mentors, and supports staff on Epic referral/authorization workflows, payer requirements, and hospital policies.
• Provides team performance feedback to supervisor as requested.
• Acts as a liaison between clinical areas, Patient Financial Services, and the Business Office teams.

QUALIFICATIONS

Required

• High school diploma or equivalent.
• Three (3) years of experience in healthcare revenue cycle, referrals, authorizations, or patient financial services.
• Proficiency in Epic or similar EMR system.
• Strong knowledge of payer authorization and referral requirements.

Preferred

• Associate’s degree in business, healthcare administration, or related field.
• Five (5) years of experience in healthcare revenue cycle, referrals, authorizations, or patient financial services Prior experience in a Critical Access Hospital (CAH) or rural healthcare setting.
• Knowledge of CMS guidelines, insurance payer contract compliance, and medical necessity criteria.
• Demonstrated leadership or lead role experience.

WORK ENVIRONMENT AND PHYSICAL DEMANDS

This position is primarily worked in an office environment.  Primarily stationary with occasional standing, walking, lifting, reaching carrying, kneeling, bending, stooping, pushing and pulling of objects weighing up to 20lbs.  The position requires continuous finger dexterity and fine manipulation.

The employee must demonstrate the ability to perform the essential functions of the position, with or without reasonable accommodation.

If you are looking for a rewarding career with a great team, you'll enjoy your career with us !

POSITION DETAILS

Hours per week:

Employee Status:

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Pay Range:

Actual pay offered will vary based on years of experience.

EMPLOYEE BENEFITS

Our benefit package includes medical, dental, vision, life insurance, and retirement options (403(b) & 457). Medical insurance coverage begins on day one and is available to both full timeand part time employees. Additionally, employees receive discounts on medical services provided by Whitman Hospital and Medical Clinics. Differentials apply for evening, night, and weekend shifts. Our unique PTO plan enables employees to increase their accrual with each year of service!