Surgical Authorization Specialist

JOB TITLE: Surgical Authorization Specialist SUMMARY: The Surgical 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 Surgical Authorization Specialist works independently to navigate multi- party 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. 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.

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