Pre-Authorization Specialist in Holland, Michigan at Shoreline Orthopaedics

The Preauthorization Specialist is responsible for prior authorizations for orthopaedic services. They will verify insurance, ensure medical necessity, submit and track requests, communicate outcomes, and support care coordination. They will maintain accurate documentation, assist with appeals, educate patients on coverage, and ensure HIPAA compliance.

Key Responsibilities:

• Obtain prior authorizations and referrals for orthopaedic surgeries, procedures, diagnostic imaging (MRI, CT, X-ray), injections, DME, and therapies
• Verify patient insurance eligibility, benefits, and authorization requirements
• Review clinical documentation to ensure medical necessity criteria are met
• Submit authorization requests through payer portals, phone, or fax and track status to completion
• Communicate authorization approvals, denials, and requests for additional information to providers and staff
• Work closely with physicians, clinical staff, surgery schedulers, and billing teams to prevent delays in care
• Appeal denied or partially approved authorizations when appropriate
• Maintain accurate and timely documentation in the electronic health record (EHR) and practice management systems
• Stay current on payer policies, orthopaedic procedure requirements, and authorization guidelines
• Assist patients by explaining authorization processes, coverage limitations, and potential financial responsibility
• Ensure compliance with HIPPA/regulatory requirements

• High school diploma or equivalent required
• Minimum of 1–2 years of experience in medical preauthorization, referrals, or insurance verification
• Experience in orthopaedics or a surgical specialty strongly preferred
• Knowledge of CPT, ICD-10, and medical necessity guidelines
• Familiarity with major commercial payers, Medicare, and Medicaid
• Proficiency with EHR and insurance web portals

Preferred Qualifications

• Certified Professional Biller/Coder (CPB/CPC), Certified Medical Administrative Assistant (CMAA), or similar certification preferred
• Experience with surgical authorizations and appeals
• Understanding of workers’ compensation and motor vehicle accident claims

• Primarily in an indoor clinical/office setting with moderate noise levels. Occasional lifting of 50 pounds is required. The role may require prolonged periods of standing and frequent use of computer equipment. This role requires the usage of personal protective equipment and requires in-person attendance.