Authorization and Referral Nurse

The Authorization and Referral Nurse is responsible for synthesizing clinical data to ensure accurate prior authorization documentation and for managing all aspects of incoming and outgoing referrals. Leveraging clinical expertise, this role ensures accurate intake documentation, identifies gaps in patient medical histories, and facilitates efficient resource coordination during the patient journey at BBI. The nurse plays a critical role in supporting optimal patient care, streamlining referral workflows, and maintaining compliance with regulatory requirements.

New Patient Data Entry: Enter patient intake form data into the EHR with clinical oversight to identify discrepancies, missing information, or required clarifications Apply nursing judgment to extrapolate medical history (e.g., recognizing hypertension when a patient lists a blood pressure medication but omits the condition) Initiate follow-up with BBI care teams to facilitate obtaining missing or clarifying information Prior Authorization Documentation: At the conclusion of telehealth encounters, prepare prior authorization notes for surgeon review and signature Following sacral neuromodulation trials, collect relevant data, document appropriately in the EHR, and prepare prior authorization notes for surgeon review Ensure documentation supports payer requirements and reduces delays in treatment approvals Referral Management: Seminar Patients (insurance requires PCP referral): Generate referral request letters using templates and fax to PCP offices Log dates of referral requests in the EHR appointment section Conduct follow-up calls with PCP offices until referral is secured Manage and document feedback provided to PCPs regarding outcomes Physician Referral Patients: Process incoming and outgoing referrals through provider portals (e.g., Leading Reach, UHC Provider Portal) Update referral statuses promptly throughout the referral lifecycle Track and monitor referral-related key performance indicators (KPIs) to ensure timeliness, quality, and efficiency Coordinate and send feedback reports to referring physicians Compliance & Confidentiality: Maintain compliance with HIPAA and applicable healthcare regulations Ensure all communications and documentation meet BBI compliance standards Safeguard sensitive patient data and uphold strict confidentiality protocols