Prior Authorization Specialist - 0.8 FTE

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Schedule Weekly Hours:

Job Description:

The Prior Authorization Specialist works with departments and insurance companies to obtain the necessary pre-certifications and authorizations for services ordered/scheduled by Gundersen Health System. Once received these are recorded in EPIC to ensure appropriate billing. The Prior Authorization Specialist maintains a high level of understanding of insurance companies and billing authorization requirements.

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Major Responsibilities:

1. Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients.

2. Follows up with physician offices, financial counselors, patients and third-party payers to complete the pre-certification process.

3. Collaborates with Supervisor, internal departments and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.

4. Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third party payer requirements/on-line eligibility systems.

5. Educates patients, staff and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.

6. Ensures all services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance.

7. Notifies patient accounts staff/patients of insurance coverage lapses, and self-pay patient status. May notify ordering providers if authorization/certification is denied.

8. May coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.

9. Maintains files for referral and insurance information, and enters referrals into the system.

10. Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.

11. Serves as an expert for peers across the patient access continuum

12. Meets daily productivity and quality standards associated with job requirements

13. Adheres to Gundersen’s mission statement, customer service standards and all system-wide policies and procedures.

14. Performs other job-related responsibilities as requested

Education and Learning:
REQUIRED
High School Diploma or equivalency

DESIRED
Bachelor's degree in Nursing or a related field

Work Experience:
REQUIRED
3-4 years of experience in healthcare with insurance and/or prior authorization experience

DESIRED
3-4 years In a health care related field

License and Certifications:
DESIRED

• Certified Professional Coder (CPC)
• Certified Coding Specialist (CCS)
• Registered Health Information Technician (RHIT)
• Registered Nurse (RN) licensed to practice in the state of Wisconsin
• Current certification through the American Association of Medical Assistants (AAMA) as a Certified Medical Assistant (CMA) or the National Healthcareer Association as a Certified Clinical Medical Assistant (CCMA) or National Center for Competency Testing as a National Certified Medical Assistant (NCMA) or American Medical Technologists as a Registered Medical Assistant (RMA) or any certification in coding or clinical documentation improvement

Age Specific Population Served:
Nonage Specific (N/A)

OSHA Category:
Category III - No employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.

Environmental Conditions:
Not substantially exposed to adverse environmental conditions (as in typical office or administrative work).
Subject to inside environmental conditions.

Physical Requirements/Demands Of The Position:
Sitting Frequently (34-66% or 5.5 hours)
Static Standing Frequently (34-66% or 5.5 hours)
Walking/Standing Occasionally (6-33% or 3 hours)
Repetitive Actions - Pinch Forces Frequently (34-66% or 5.5 hours)

If you need assistance with any portion of the application or have questions about the position, please contact [email protected] or call 608-775-0267

Equal Opportunity Employer