Job Details
- Type of Work:
Full-time
- Work Setup:
Hybrid
- Schedule:
40 hrs/week
Job Description
Scale Up Philippines is partnering with a growing, multi-location integrated healthcare group to hire an experienced Surgical Authorization Specialist. This is a high-impact, detail-critical revenue cycle role focused exclusively on securing prior authorizations for surgical procedures, advanced imaging, and complex interventional care across a multi-specialty orthopedic and spine practice.
You will serve as the bridge between the clinical team, payers, and patients – ensuring that every scheduled surgery and procedure is fully authorized, compliantly documented, and financially cleared before the date of service. Your work directly protects revenue, reduces denials, and keeps the surgical schedule running without interruption.
This is a hybrid role requiring deep knowledge of surgical authorization workflows, payer medical necessity criteria, and clinical documentation requirements.
Key Responsibilities:
- Initiate, track, and secure prior authorizations for orthopedic and spine surgeries, pain management procedures, ambulatory surgery center (ASC) cases, and advanced diagnostic imaging (MRI, CT).
- Review physician orders, clinical notes, operative reports, and diagnostic results to compile complete and compliant authorization request packages.
- Submit authorization requests through payer portals, fax, and phone, ensuring all supporting clinical documentation meets medical necessity criteria.
- Manage the full authorization lifecycle — from initial submission through approval, peer-to-peer review coordination, appeals, and denial resolution.
- Coordinate peer-to-peer review requests between the treating physician and the payer’s medical reviewer when initial authorization is denied.
- Monitor authorization expiration dates and initiate renewals or extensions proactively to avoid lapses that could delay surgery.
- Communicate authorization status clearly and promptly to surgeons, surgical coordinators, clinical staff, and patients.
- Identify and escalate urgent or time-sensitive cases to prevent surgical schedule disruptions.
- Maintain accurate and organized authorization records, approval numbers, and payer correspondence in the EHR/practice management system (NextGen preferred).
- Stay current on payer-specific surgical coverage policies, CPT/ICD-10 coding requirements, and medical necessity guidelines — particularly for orthopedic, spine, and pain management procedures.
- Work closely with the insurance verification, billing, and front office teams to ensure seamless pre-surgical financial clearance.
- Support the appeals process by gathering clinical documentation and drafting appeal letters in response to authorization denials.
Qualifications:
Minimum 1+ years of experience in surgical prior authorization or pre-certification within a US healthcare setting — orthopedic, spine, neurosurgery, or pain management specialty experience is required.
Deep knowledge of surgical authorization workflows including submission, follow-up, peer-to-peer coordination, and appeals.
Strong understanding of CPT and ICD-10 coding as they apply to orthopedic and spine surgical procedures.
Familiarity with medical necessity criteria and clinical documentation requirements for major US payers (Medicare, Medicaid, BCBS, Aetna, Cigna, UnitedHealthcare, and managed care plans).
Hands-on experience with payer portals such as Availity, NaviMedix, or direct insurance portals.
Experience with EHR/practice management system
Strong written and verbal English communication skills — able to engage confidently with payer representatives, clinical staff, and surgeons.
Highly organized, proactive, and able to manage multiple open authorizations simultaneously without losing track of timelines or deadlines.
Experience handling auto accidents (no-fault) or workers’ compensation surgical authorizations is a significant plus.
Reliable and stable internet connection.
Why Join Scale Up Philippines?
At Scale Up Philippines, we connect talented Filipino professionals with world-class clients who value people as much as results. This one is for someone ready to grow.
If you’re passionate about this position and ready to grow your career with a global team, we’d love to hear from you!
