Prior Authorization Specialist
On-siteNewcastle, Wyoming, United States
Job Summary
Verify patient insurance eligibility, coverage, and benefits prior to scheduled services across the hospital, skilled nursing facility, and outpatient clinics. Determine pre-certification and prior authorization requirements for all departments, then obtain necessary approvals from third-party payers before services are rendered. Submit accurate data elements including CPT and diagnosis codes, enter authorization numbers into the registration and accounting system, and escalate financial clearance risks such as coverage gaps or self-pay situations. Communicate with patients, insurers, and physician offices regarding authorization status and notify staff of approved lengths of stay or concurrent review requirements. Maintain current knowledge of payer-specific timelines for Medicare, Medicaid, and commercial payers while documenting all financial clearance work according to established standards.
Required Qualifications
- High School Diploma or equivalent
- Two years' experience in a medical business office, patient registration, or health care setting involving insurance verification, authorization, or patient-facing customer service, or an equivalent combination of education and experience
- Working knowledge of insurance eligibility, benefits, pre-certification, and prior authorization processes for Medicare, Medicaid, and commercial payers
- Proficiency with electronic health record and patient registration/accounting systems
- Good math skills and the ability to spot numerical errors
- Strong written and oral communication skills
- Excellent verbal and written communication skills
- Excellent interpersonal, negotiation, and conflict resolution skills
- Excellent organizational skills and attention to detail
- Excellent time management skills with a proven ability to meet deadlines
- Strong analytical and problem-solving skills
- Has the ability to prioritize tasks and to delegate them when appropriate
- Has the ability to act with integrity, professionalism, and confidentiality
- Has the ability to determine an appropriate course of action in more complex situations
- Has the ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
- Has the ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
- Has the ability to perform basic mathematical calculations and to balance and reconcile figures accurately
- Has the ability to maintain confidentiality of all medical, financial, and legal information
- Has the ability to complete work assignments accurately and in a timely manner
- Has the ability to communicate effectively, both orally and in writing
- Has the ability to handle difficult situations involving patients, physicians, payers, or others in a professional manner
- Must be able to access, find, and navigate each department at WCHS
- Position requires light to moderate work with 50 pounds maximum weight to lift and carry
- Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing
- Occasional after-hours calls may occur
Desired Qualifications
- Completion of post-secondary coursework in medical terminology and CPT/diagnosis coding, or graduation from a medical assistant, health unit coordinator, or health care business services program, preferred
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