Surgical Authorization Specialist (Clifton)

JOB TITLE: Authorization Specialist SUMMARY: The Authorization Specialist at Progressive Spine & Orthopaedics is responsible for securing and managing surgical authorizations, with a focus on complex cases involving Motor Vehicle Accidents (MVA), Workers’ Compensation (WC), and Personal Injury Protection (PIP). This role requires strong knowledge of out-of-network processes, legal documentation requirements, and payer-specific regulations. The Authorization Specialist works independently to navigate communications between insurance carriers, attorneys, adjusters, and healthcare providers to ensure timely approvals and accurate records, helping to prevent surgical delays. DUTIES AND RESPONSIBILITIES: • Obtain surgical authorizations for cases involving out-of-network carriers, WC, MVA and PIP, ensuring compliance with state regulations and carrier requirements. • Review and compile necessary clinical and legal documentation, including letters of medical necessity, operative notes, accident reports, and attorney requests. • Communicate regularly with attorneys, adjusters, and case managers to secure required approvals and resolve documentation gaps. • Track and follow up on pending authorizations to avoid delays in surgery scheduling. • Navigate unique or complex payer situations, such as multiple insurance carriers or disputed claims. • Submit appeals for denied authorizations, preparing thorough documentation and coordinating with physician for peer-to-peer reviews when needed. • Maintain detailed, accurate records in the EMR for every authorization case, including all correspondence, phone calls, and submitted materials. • Stay informed on state-specific WC and PIP authorization rules and changes in insurance carrier processes. • Coordinate with Surgical Coordinators to ensure authorization status is clearly communicated and any delays are addressed proactively. • Prioritize workload to meet strict surgery timelines while handling a high volume of cases. • Performs other related duties as assigned by management. QUALIFICATIONS: • High school diploma or equivalent; additional education or certification in healthcare administration or related field preferred. • Minimum of 2 years’ experience in medical or surgical authorization, with direct experience in WC, MVA, and PIP cases preferred. • Strong understanding of out-of-network authorization processes, state WC regulations, and PIP laws. • Experience communicating with attorneys, adjusters, and case managers. • Knowledge of medical terminology and surgical procedures, preferably orthopaedic. • Proficiency with EMR systems, insurance portals, and Microsoft Office applications. • Excellent attention to detail, organizational skills, and ability to manage multiple priorities in a fast-paced environment. • Strong verbal and written communication skills. Professional demeanor and commitment to patient-centered service. • Bilingual skills a plus. GENERAL EXPECTATIONS: • Maintain confidentiality of patient and practice information in compliance with HIPAA. • Work collaboratively with physicians, staff, and external parties to achieve timely authorizations. • Demonstrate professionalism, reliability, and respect in all communications. • Complete work accurately and within established timelines, even under high caseload pressure. COMPENSATION: Pay based on experience and qualifications. In accordance with the New Jersey Pay Transparency Act, this position falls within Pay Grade 7 of the 2025 OPM Salary Table for the NY, NJ, CT, and PA region. PHYSICAL DEMANDS AND WORK ENVIRONMENT: Typical office environment with sitting, standing, and extensive computer use. Manual dexterity required for handling documentation and keyboarding.

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