Surgery Prior Authorization Specialist

Job Type

Full-time

Department: Billing

Reports to: Revenue Cycle Manager

Status: Full-Time, Non-Exempt

Wage: $20.00 – $28.00 per hour, commensurate with experience

Bonus Eligibility: No

Boulder Centre for Orthopedics & Spine is seeking a Surgery Prior Authorization Specialist to join our Revenue Cycle team. This position plays an important role in ensuring surgical procedures are properly authorized and financially prepared before a patient's scheduled surgery.

The ideal candidate is highly organized, detail-oriented, and comfortable working with insurance carriers, providers, clinical staff, and surgery schedulers. This role requires the ability to understand insurance benefits and payer requirements, manage multiple authorization requests, and proactively identify issues that could delay a patient's care.

• Obtain and manage prior authorizations for surgical procedures.
• Verify insurance eligibility, benefits, authorization requirements, and payer-specific guidelines.
• Review surgical orders and supporting clinical documentation to ensure you meet authorization requirements.
• Submit authorization requests through payer portals, by phone, or through other required processes.
• Track pending authorizations and follow up with insurance carriers to ensure timely determinations.
• Identify authorization requirements, site-of-service restrictions, and other payer guidelines that may impact surgical scheduling.
• Ensure surgical procedures are scheduled at the appropriate facility based on insurance requirements and medical necessity criteria.
• Identify cases requiring hospital versus ambulatory surgery center (ASC) scheduling based on payer restrictions or procedure requirements.
• Communicate authorization status, restrictions, denials, or potential delays to surgery schedulers, providers, clinical staff, and other appropriate team members.
• Proactively identify missing information or documentation and coordinate with providers and clinical staff to obtain what is needed.
• Escalate complex, urgent, or high-risk authorization issues as appropriate.
• Assist with denied, delayed, retroactive, and appeal requests as needed.
• Maintain accurate and timely documentation of authorization activity in the appropriate systems.
• Perform insurance verification and assist with determining patient financial responsibility for scheduled surgical services.
• Review deductibles, coinsurance, out-of-pocket maximums, and applicable benefits to support accurate patient cost estimates.
• Communicate with patients regarding estimated financial responsibility and pre-service requirements when applicable.
• Coordinate with surgery schedulers, billing staff, providers, facilities, and insurance carriers to ensure surgical cases are financially and administratively .
• Monitor surgical readiness and notify appropriate team members of missing authorizations, unresolved financial requirements, or other issues that affect scheduling.
• Maintain knowledge of changing payer requirements, authorization processes, and insurance guidelines.
• Support departmental productivity, accuracy, timeliness, and revenue cycle goals.
• Perform other duties and responsibilities as assigned.

• High school diploma or GED.
• At least 2 years of experience in medical insurance, prior authorization, medical billing, revenue cycle, or a related healthcare setting.
• Experience working with insurance companies and payer portals.
• Strong knowledge of insurance benefits and prior authorization processes.
• Knowledge of medical terminology and familiarity with CPT and ICD-10 coding.
• Strong attention to detail and organizational skills.
• Ability to manage multiple cases and deadlines in a fast-paced environment.
• Excellent written and verbal communication…