Prior Authorization/Referral Specialist
$35,360–$52,520 year
On-sitePleasant Prairie, Wisconsin, United States
Job Summary
Verify insurance eligibility and benefits for scheduled services to determine prior-authorization or referral requirements. Initiate and follow through on authorization requests with payors, collecting clinical documentation to support medical necessity. Document all activities in the electronic health record and communicate status clearly to providers, clinical staff, and patients. Coordinate with teams to obtain additional information required by payors and maintain up-to-date knowledge of coding guidelines and payer policies. Ensure timely resolution of authorization issues to prevent care delays. Participate in continuous quality improvement efforts including audits and training.
Required Qualifications
- High School or GED
- One (1) year of insurance/prior authorization experience (preferred)
- Experience and familiarity with using insurance portals
- Strong customer service orientation with excellent interpersonal and computer skills
- Working knowledge of medical terminology and healthcare documentation standards
- Demonstrated ability to manage time effectively, prioritize tasks, and maintain accuracy in a high-volume environment
- Proficient with internet-based tools, email communication, and Microsoft Office applications (e.g., Word, Excel, Outlook)
- Strong written and verbal communication skills, with the ability to interact professionally with patients, clinicians, and insurance representatives
- Proven experience in prior authorizations, referrals, patient registration, insurance verification, and understanding of various health insurance plans (preferred)
- Proficient in navigating online prior authorization portals and working with multiple commercial and government payors (preferred)
- Knowledge of medical coding systems, including ICD-10, CPT, and HCPCS codes (preferred)
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