Job Description

Job Brief:

The Prior Authorization & Referral Coordination Specialist serves as a dedicated resource supporting patient access programs. This role is responsible for determining payer requirements, obtaining physician referrals, collecting clinical documentation, submitting prior authorizations, tracking approvals, and coordinating communication between insurance payers, referring providers, patients, and internal scheduling teams.

The specialist acts as the central point of coordination throughout the patient access journey, ensuring all referral, authorization, and documentation requirements are completed accurately and timely so patients can be scheduled for Eversense Continuous Glucose Monitoring (CGM) insertion procedures.

Success in this role requires strong payer knowledge, exceptional provider outreach skills, persistence in document collection, and the ability to manage multiple cases while maintaining detailed documentation and compliance standards

Job Duties and Responsibilities:

Prior Authorization Management

• Verify whether an authorization is required for Eversense CGM insertion procedures.
• Review payer requirements and medical policies.
• Compile complete authorization packets.
• Submit prior authorization requests through appropriate payer channels.
• Follow up on pending requests until a determination is received.
• Coordinate approval, denial, resubmission, reconsideration, and additional documentation requests.
• Track authorization expiration dates and renewal requirements.
• Maintain complete audit trails for all authorization activities.

Provider Outreach & Document Collection

• Contact PCP offices, endocrinologists, referral coordinators, and clinic staff to obtain:
• Review documentation for payer-specific requirements.
• Identify deficiencies that may cause denials or delays.
• Request corrections and updated documentation proactively.
• Maintain persistent follow-up cadence until documentation is received.

Patient Scheduling Readiness Support (NEW)

• Monitor patient cases from referral initiation through authorization completion.
• Ensure all requirements are met before scheduling.
• Communicate approval outcomes to operational and clinical teams.
• Coordinate handoff to scheduling teams once the patient is cleared.
• Help minimize patient wait times by removing access barriers quickly.
• Maintain visibility of pipeline status and next steps throughout the authorization process.

Additional Preferred Qualifications:

Strongly Preferred

• Experience obtaining physician referrals from PCP offices.
• Experience working with specialty care referral programs.
• Experience supporting endocrinology, diabetes, or CGM-related healthcare services.
• Experience coordinating patient scheduling after insurance approval.
• Experience managing payer-specific referral requirements.
• Experience handling high-volume provider outreach campaigns.
• Familiarity with Eversense CGM or diabetes-focused healthcare programs.
• Experience working in patient access, reimbursement, benefits investigation, or authorization support programs

Ideal Candidate Profile

The ideal candidate is a highly persistent healthcare professional who understands how to navigate payer requirements, physician referral processes, and prior authorization workflows. They are comfortable making frequent outbound calls to PCP offices and insurance companies, obtaining missing documentation, securing approvals, and driving cases through to patient scheduling.

This person excels at:

• Provider relationship management
• Referral coordination
• Prior authorization submissions
• Medical records retrieval
• Documentation review
• Insurance navigation
• Patient access coordination

Their ultimate responsibility is ensuring that patients eligible for Eversense CGM therapy successfully move from referral to authorization to scheduling with minimal delays.

Job Required Qualification:

• Minimum 3-year solid experience with US Healthcare Insurance
• At least 1 year work experience in a customer service call center (Voice and Back office)
• Strong knowledge of prior authorization and document Collection/Chase workflows
• Familiarity with EMR, DME systems, payer portals, and database entry
• Strong understanding of HIPAA compliance and medical terminology
• Experience with medical RCM LOBs like Prior Authorizations and Document Collection/Chase.
• High attention to detail and documentation accuracy
• Excellent Customer service skills, including phone and interpersonal skills.
• Ability to manage high volume workloads and meet performance targets
• Typing speed of at least 35 WPM with high accuracy
• Database data entry experience preferred.
• Proficiency in MS Word, Excel, and Outlook
• Strong English proficiency, both written and verbal
• Strong attendance, reliability, and accountability
• Ability to work effectively with diverse teams and clients
• High comfort level working with culturally diverse team members and clients.

Preferred Qualifications:

• Startup / rapid growth experience
• Life sciences, pharmaceutical, or medical device experience.
• Knowledge of medical terminology preferred.
• Knowledge on diabetes or diabetes supplies and any other DME.