Surgical Authorization Specialist at Progressive Spine and Orthopaedics LLC – Clifton, New Jersey

Job Title: Authorization Specialist
Position Summary

The Authorization Specialist is responsible for obtaining and managing authorizations for surgical procedures across a variety of payer types, including commercial insurance, out-of-network plans, Personal Injury Protection (PIP), and Workers’ Compensation (WC). This role requires strong knowledge of payer-specific requirements, surgical authorization workflows, and follow-up processes to ensure timely approvals and prevent delays in patient care. The Authorization Specialist works closely with providers, billing staff, surgical coordinators, insurance carriers, adjusters, attorneys, and case managers to support efficient and accurate authorization management.

Essential Duties and Responsibilities:
- Obtain surgical authorizations for procedures involving commercial payers, out-of-network plans, PIP, and Workers’ Compensation.
- Review patient accounts and verify insurance requirements to determine authorization needs prior to scheduling or treatment.
- Prepare, submit, and track authorization requests with the appropriate payer or carrier.
- Gather and compile required documentation, including clinical notes, surgical orders, letters of medical necessity, imaging reports, operative reports, and other supporting records.
- Communicate with insurance representatives, adjusters, attorneys, nurse case managers, physician offices, and internal departments to secure approvals and resolve missing information.
- Monitor pending authorizations and follow up regularly to avoid delays in surgery scheduling or treatment.
- Investigate and resolve authorization denials, including submission of reconsiderations or appeals and coordination of peer-to-peer reviews when needed.
- Document all authorization activity, correspondence, phone calls, and status updates accurately in the electronic medical record and other tracking systems.
- Work collaboratively with the billing department and surgical scheduling team to ensure smooth coordination between authorization, claim processing, and patient care workflows.
- Maintain working knowledge of payer guidelines, authorization rules, and regulatory requirements related to commercial insurance, out-of-network cases, PIP, and WC.
- Assist with identifying trends, workflow issues, and opportunities to improve authorization turnaround times and reduce denials.
- Perform other related duties as assigned by management.

Qualifications:
- High school diploma or equivalent required; additional education in healthcare administration, medical billing, coding, or a related field preferred.
- Minimum 5 years of experience preferred in medical or surgical authorizations.
- Demonstrated experience with out-of-network authorizations, surgical authorization, commercial payers, PIP, and Workers’ Compensation required.
- Strong understanding of payer guidelines, insurance verification, authorization requirements, and appeals processes.
- Knowledge of medical terminology, surgical procedures, and orthopedic or spine specialties preferred.
- Experience working with attorneys, adjusters, case managers, and insurance carriers is strongly preferred.
- Proficiency with EMR systems, payer portals, and Microsoft Office applications.
- Excellent organizational skills with the ability to manage multiple accounts and deadlines in a fast-paced environment.
- Strong written and verbal communication skills.
- High level of accuracy, attention to detail, and professionalism.
- Bilingual skills are a plus.

General Expectations:
- Maintain confidentiality of patient and practice information in accordance with HIPAA guidelines.
- Demonstrate professionalism, accountability, and effective communication in all interactions.
- Work collaboratively with clinical, scheduling, and billing teams to support timely patient care and revenue cycle efficiency.
- Complete work accurately and within established timelines while managing a high-volume workload.

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 prolonged sitting, computer use, and frequent communication with internal staff and external payer representatives.