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.
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.|
|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
|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|
|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||problem solve|
|Reasoning/Decision Making||have positive attitude|
|Communication||communicate with ease on a professional level|
|License and Certifications|
|Desired||Certified Professional Coder (CPC)
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)
|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:|
||Number of lbs:|
|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