Referral & Prior Authorization Specialist | Permanent WFH

Update 9/25: Need to have: new patient referral and prior authorization (with opthamology ideally), EPIC experience, ophthalmology experience

We are seeking an experienced Referral & Prior Authorization Specialist with a strong background in ophthalmology, referral management, insurance verification, and prior authorizations. The ideal candidate will have hands-on experience managing referrals from intake through scheduling and authorization approval, with a strong understanding of ophthalmic services, diagnostic testing, procedures, and injectable medications.

This role supports a high-volume academic ophthalmology practice handling approximately 30–50 new referrals per day. The successful candidate must be highly organized, persistent, detail-oriented, and comfortable communicating directly with insurance carriers, referring offices, patients, providers, and clinical staff.

Key Responsibilities

• Receive, review, log, and process new referrals from Epic work queues, fax, patient portals, and phone.
• Review referrals for completeness, including clinical notes, diagnosis, referring provider information, and insurance details.
• Triage referrals based on urgency and complexity and escalate urgent cases to clinical staff when needed.
• Verify patient insurance eligibility, benefits, and plan participation.
• Determine whether office visits, diagnostic testing, injectable medications, or procedures require prior authorization or payer referrals.
• Schedule new patients with the appropriate provider and ophthalmology subspecialty.
• Follow up with referring offices for missing records or documentation and ensure referrals are closed out appropriately.
• Submit, monitor, and follow up on prior authorizations for office visits, diagnostic testing, surgeries, procedures, and injectable medications.
• Prioritize intravitreal injection drug authorizations to ensure treatment is not administered without the required approval.
• Prepare complete authorization submissions using CPT, HCPCS, and ICD-10-CM codes, clinical documentation, and supporting medical records.
• Monitor surgical cases for procedure or coding changes and update or obtain additional authorizations when necessary.
• Track authorization approvals, visit limits, expiration dates, and renewal requirements.
• Initiate authorization renewals before existing approvals expire.
• Coordinate peer-to-peer reviews between providers and insurance carriers when required.
• Contact payers by phone and through online portals to check authorization status, provide additional information, and resolve pending requests.
• Support authorization-related denials and appeals by gathering authorization records, medical documentation, and supporting information.
• Communicate with patients regarding referral progress, authorization status, scheduling, and financial responsibility.
• Serve as a liaison between patients, referring offices, insurance carriers, providers, clinical teams, and billing.
• Identify recurring payer issues, authorization delays, or referral backlogs and escalate trends to leadership.
• Maintain detailed documentation in Epic, including payer communications, reference numbers, authorization status, and follow-up dates.
• Maintain strict compliance with HIPAA, payer requirements, and organizational policies and procedures.
  
  

Qualifications

• 2+ years of experience in prior authorization, referral management, insurance verification, or a related healthcare role.
• Ophthalmology experience required.
• Hands-on experience with Epic, particularly Referrals, Cadence, Prelude, or authorization work queues.
• Experience submitting and tracking authorizations with commercial insurance carriers, Medicare, and Medicaid.
• Working knowledge of CPT, HCPCS, ICD-10-CM, and medical terminology.
• Experience communicating directly with insurance carriers through phone and payer portals.
• Experience working with patients and referring provider offices.
• Ability to manage a high volume of referrals and authorizations while prioritizing urgent and time-sensitive cases.
• Strong documentation, account-note, and follow-up skills.
• Excellent verbal and written communication skills.
• Exceptional attention to detail and accuracy.
• Proficiency with Microsoft Office and standard healthcare applications.
• Ability to work independently in a remote environment.
• Reliable high-speed internet and a private, HIPAA-compliant workspace.
• Availability to work Monday through Friday during Eastern Time business hours.
• Experience in a retina or ophthalmology practice.
• Experience obtaining authorizations for intravitreal injection drugs, including Eylea, Lucentis, Vabysmo, and Avastin/anti-VEGF medications.
• Experience with ophthalmic surgery authorizations.
• Experience with buy-and-bill medications, specialty pharmacy, or manufacturer assistance programs.
• Familiarity with vision plans such as VSP, EyeMed, and Davis Vision, including the distinction between vision and medical insurance for ophthalmic care.
• Experience working in an academic medical center or hospital environment.
• Experience handling medical-necessity denials, authorization-related denials, and appeals.
• CPAR, CMAA, CPC, or COA certification.
  
  

Perks

• Permanent Work From Home
• Leave Credits
• Monetary Allowance
• Annual Bonus
• Weekly Paychecks
• Fixed Weekends Off
• Thriving Company Culture with Complete Autonomy
• Exclusive Specialized Training Programs
• Unlock Your Potential with a Highly Competitive Salary
  
  

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