Prior Authorization Specialist (Tomah, WI)
Department Prior Auth and DME Services
Location Tomah
Schedule/Shift Days
FTE 1 FTE
Benefit Eligible Yes
Temporary Position No
Job Details

This position will typically work Monday - Friday from 8:00am - 5:00pm within our Revenue Cycle team located in Tomah, WI with the potential of adding extended hours in the future.


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.

Job Responsibilities
  • Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients.  Follows up with physician offices, financial counselors, patients and third-party payers to complete the pre-certification process.

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

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

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

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

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

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

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

  • 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

  • Serves as an expert for peers across the patient access continuum

  • Meets daily productivity and quality standards associated with job requirements

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

  • Performs other job-related responsibilities as requested

  • Scope of the Job
    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.
    Position Qualifications
    Education and Experience:
    Required High School Diploma or equivalency 
    Desired Bachelor's degree in  Nursing from an accredited college of nursing, as recognized by the Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education. 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
    Skills:
    Required Ability to...
    Computer Systems/Software/Applications use Microsoft Office Products, Adobe and other similar applications
    Computer Systems/Software/Applications operate computer
    Communication excellent oral and written communication skills
    General - All Positions provide excellent customer service to people both inside and outside the organization
    General - All Positions work cooperatively with a wide variety of people
    Organization time management skills
    Organization organize and monitor multiple projects and files to ensure timely and accurate completion
    Reasoning/Decision Making be flexible
    Reasoning/Decision Making be determined
    Reasoning/Decision Making cooperate
    Reasoning/Decision Making problem solve
    Reasoning/Decision Making have positive attitude
    Desired Ability to...
    Communication communicate with ease on a professional level
    License and Certifications
    Required
    Desired Certified Professional Coder (CPC)  and 
    Certified Coding Specialist (CCS)  and 
    Registered Health Information Technician (RHIT)  and 
    Registered Nurse (RN) licensed to practice in the state of Wisconsin and 
    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 
    any certification in coding or clinical documentation improvement 
    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)
    Driving
    Stooping/Bending
    Squatting
    Kneeling/Half Kneel
    Climbing Stair
    Climbing Ladder
    Reaching - Shoulder Level
    Reaching - Below Shoulder
    Reaching - Above Shoulder
    Repetitive Actions - Pinch Forces Frequently (34-66% or 5.5 hours) Pounds of force:
    Repetitive Actions - Grip Forces Pounds of force:
    Repetitive Actions - Fine Manipulation
    Balance - Right Leg
    Balance - Left Leg
    Lifting - Floor to Waist Number of lbs:
    Lifting - Waist to Overhead Number of lbs:
    Lifting - Other Number of lbs:
    Carrying - Long Carry (>50 feet) Number of lbs:
    Carrying - Short Carry Number of lbs:
    Carrying - Right Carry Number of lbs:
    Carrying - Left Carry Number of lbs:
    Carrying - Push/Pull (Static Force) Number of lbs:
    Other:
    Number of lbs:
    Environmental Conditions
    Subject to inside environmental conditions.
    Not substantially exposed to adverse environmental conditions (as in typical office or administrative work).

    Prior Authorization Specialist (Tomah, WI)

    Equal Opportunity Employer