Prior Authorization Specialist

Job Description

Job Description

Are you detail-oriented and enjoy helping patients understand their healthcare coverage? Join our team as a Patient Benefits Specialist and make a meaningful difference every day!

In this role, you'll be an essential part of the patient care journey - working closely with providers, insurance companies, and patients to ensure services are authorized and ready to go. You'll handle pre-authorizations and pre-certifications for upcoming procedures, special testing, and referrals. You'll also connect with patients before their appointments to review coverage and financial responsibility, helping them feel informed and confident about their care.

We're looking for someone who's organized, compassionate, and comfortable navigating insurance details in a fast-paced clinical setting.

This is a full-time, on-site position based in our Wausau office (1.0 FTE) with the potential for a hybrid schedule once fully trained and proficient in the role!

Essential Job Functions and Responsibilities:

• Obtains pre-authorizations/pre-certifications for procedures, radiology/diagnostic testing, laboratory services, and other special testing as required by insurers or managed care providers.
• Works with reception and clinical staff to coordinate referrals to outside facilities or providers.
• Verifies Medicare, Medicaid and other health insurance eligibility prior to patient services and procedures.
• Contacts patients prior to appointment or procedure to discuss insurance coverage and benefits and patient financial responsibility.
• Informs Patient Account Representatives of new or updated insurance plans to ensure patient claims are submitted correctly.
• Works with clinical staff to manage appointment frequency, insurance coverage, and benefits for patients on infusion therapy.
• Maintains up-to-date knowledge of clinical guidelines, precertification requirements, and medical policies for services and procedures by routinely reviewing payer newsletters, regulatory and payer websites, and professional resources.
• Acts as administrator for the insurance websites and obtains and maintains logon access to all payers' websites.
• Performs other duties as assigned.

Minimum Qualifications

• Education
  • High school diploma or equivalent required.
• Licensure/Certification
  • Advanced training/certification in medical billing, coding, and/or insurance preferred.
• Experience
  • Minimum of one-year experience in a medical billing role is required, or equivalent education.

Competencies Required

• Knowledge
  • Working knowledge of medical and insurance terminology.
  • Basic knowledge of medical and insurance terminology, CPT, HCPCS, and ICD-10 coding.
• Skills
  • Possesses interpersonal, communication, and listening skills necessary to deal effectively and courteously with patients and all staff members.
  • Proficient computer skills working in an Electronic Medical Record (EMR) and Practice Management software, and Microsoft Word, Excel, and the Internet.
  • Demonstrates professionalism and respect in all forms of communication and correspondence.
• Abilities
  • Ability to maintain strict confidentiality of fiscal and health information.
  • Ability to work in a fast paced, multi-tasking environment and cope with rapidly changing demands while working as a team member.
  • Ability to prepare and gather information accurately and efficiently.