Preauthorization Specialist - Northeast Georgia Physicians Group Ngpg - Orthopedics - FT Days - CPC Certification Required

Job Category:

Administrative & Clerical

Work Shift/Schedule:

8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Preauthorization Specialist is responsible for securing timely and accurate insurance authorization and precertification for procedures, diagnostic tests, and other clinical services within a physician enterprise setting. This role ensures compliance with payer requirements, supports clinical operations, and helps optimize reimbursement by preventing claim denials related to authorization issues. The specialist works closely with providers, clinical staff, patients, and insurance companies to ensure all required documentation is obtained and processed efficiently.

Minimum Job Qualifications

• Licensure or other certifications: CPC Certification

• Educational Requirements: High School Diploma or GED

• Minimum Experience: 3-5 years of relevant experience in insurance authorization, precertification, medical billing, revenue cycle, patient access, or related healthcare operations in a physician practice or medical group setting in lieu of CPC certification accepted.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications: CPB, CCA, CCS, or similar coding/billing credentials are beneficial and are strongly preferred.

• Preferred Educational Requirements:

• Preferred Experience: Prior experience supporting specialties with complex authorization needs (e.g., cardiology, orthopedics, surgery, neurology, imaging). Experience working in a multi-site physician enterprise or healthcare system setting.

• Other:

Knowledge, Skills and Abilities

• Strong understanding of payer authorization requirements for procedures and diagnostic services.

• Familiarity with commercial insurance, Medicare, Medicaid, managed care plans, and medical necessity guidelines.

• Ability to read and understand clinical documentation.

• Excellent communication and customer service skills.

• Strong attention to detail, organization, and follow-through.

• Proficiency with EHR systems, payer portals, and Microsoft Office applications.

• Ability to work independently in a fast-paced physician enterprise environment.

Essential Tasks and Responsibilities

Preauthorization & Precertification

• Verify whether procedures, imaging studies, surgeries, outpatient services, and specialty referrals require prior authorization based on payer rules.

• Submit authorization requests through payer portals, phone outreach, or fax, ensuring accuracy and completeness of clinical information.

• Obtain necessary medical records, clinical notes, and supporting documentation to submit with each authorization request.

• Track authorization status and follow up with payers to avoid delays in patient care.

• Document all authorization activities in the EHR and practice management systems accurately and in real time.

Insurance Coordination

• Review insurance benefits, eligibility, and coverage requirements for upcoming procedures.

• Communicate authorization outcomes to scheduling teams, providers, and patients.

• Identify and escalate issues involving coverage gaps, medical necessity denials, or incomplete clinical information.

Collaboration & Communication

• Work closely with physicians, advanced practice providers, nurses, and scheduling staff to ensure all clinical data needed for authorization is available.

• Notify departments of pending or unresolved authorizations that may impact scheduling or reimbursement.

• Provide guidance to clinic teams on payer authorization requirements and documentation recommendations.

Compliance & Documentation

• Maintain detailed, accurate authorization records that support audit readiness.

• Ensure compliance with payer rules, regulatory requirements, and organizational policies.

• Participate in process improvement activities to enhance authorization efficiency and accuracy.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Constantly 66-100% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.