Medical Coding & Prior Authorization Specialist

Medical Coding & Prior Authorization Specialist

Full Time / Days / On-Site 40 hours per week Come join our team! Crossing Rivers Health provides competitive pay along with an excellent benefits package including medical, dental, vision; life insurance, short term disability, paid time off, a retirement plan w/company match, and more! Crawford County Relocation Opportunity - Talent Recruitment Grant

Crossing Rivers Health is excited to partner with Driftless Development, Inc. to secure the newly awarded Talent Recruitment Grant by Wisconsin Economic Development Corporation (WEDC). Come Home to River Country is an initiative designed to attract and retain talent by offering a relocation incentive for out-of-state households moving to Crawford County, Wisconsin. Click here for more information. Driftless Development

Our core values are practiced and exhibited throughout the organization in our actions and in services provided. Joy: Unity: Integrity: Compassion: Excellence

The Medical Coding and Prior Authorization Specialist plays a dual role in supporting accurate clinical documentation and ensuring timely authorization of services for patients at Crossing Rivers Health. This position is responsible for coding all/assigned encounter types; reviewing and correcting coding related denials and managing prior authorization processes for specialty services, surgical procedures, therapies and imaging. The goal of this role is to support compliance, maximize reimbursement and ensure patients have timely access to medically necessary care.

Essential Job Functions

• Reviews clinical documentation to ensure coding accuracy, completeness, and compliance with regulations.
• Assigns diagnoses, procedural/treatment, professional billing codes for all patient type encounters (Clinic, Center for Specialty Care, Emergency, Urgent Care, Outpatient Services, Lab, Imaging, Physical/Occupational/Speech Therapy, Surgery, Observation/Inpatient, Obstetrics) utilizing ICD-10-CM, ICD-10-PCS or CPT guidelines
• Working knowledge of modifier usage, CCI edits, HCPCS, LCD/NCI regulations
• Data entry/verification/appropriate sequencing into electronic health record
• Submit provider queries as appropriate following approved guidelines.
• Identify and resolve clinical documentation and charge capture data discrepancies
• Initiates and manages prior authorization requests for surgical procedures, specialty services, imaging, and rehabilitation therapies.
• Verifies medical necessity and payer-specific criteria prior to submission of authorization requests.
• Assists with denial follow-up and appeals related to coding or prior authorization
• Collaborates with providers, nursing staff, and scheduling teams to obtain required clinical documentation for approvals.
• Monitors pending authorizations, ensuring timely follow-up and communication with payers, providers, and patients.
• Tracks and reports trends in authorization denials and coding discrepancies; participates in denial prevention initiatives.
• Maintains current knowledge of payer guidelines, coding updates, and regulatory requirements.
• Supports staff and providers through education on documentation and authorization best practices.
• Contributes to a culture of accountability, continuous improvement, and patient-centered service.
• Assist in provider education in use of coding guidelines and practices and proper documentation techniques
• Assist with coding quality review activities for accuracy and compliance monitoring
• Commitment to continuous learning as required to stay up-to-date on coding and prior authorization guidelines.
• Other job duties and responsibilities as assigned to effectively meet the needs of the patients, the department, and the organization as a whole.

Competencies

• Accountability Ability to accept responsibility and account for his/her actions.
• Accuracy Ability to perform work accurately and thoroughly.
• Business Acumen Ability to grasp and understand business concepts and issues.
• Communication The ability to get one's ideas across to others through oral or written means and to understand the ideas of others through effective listening skills.
• Detail Oriented Ability to pay attention to the minute details of a project or task.
• Ethical Ability to demonstrate conduct conforming to a set of values and accepted standards.
• Honesty/Integrity Ability to be truthful and be seen as credible in the workplace.
• Organized Possessing the trait of being organized or following a systematic method of performing a task.
• Reliability The trait of being dependable and trustworthy.
• Responsible Ability to be held accountable or answerable for one's conduct.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Requirements

Education

• High School Graduate or General Education Degree (GED) : Required
• Associate's Degree in Health Information Management, Medical Coding, OR related/Medical Coding diploma/educational program: Required
• Registered Health Information Technician or related Medical Coding certification within 6 months of hire.

Experience

• 2+ years of medical coding experience in a Critical Access Hospital or similar setting preferred.
• Prior authorization and insurance verification experience preferred.

Computer Skills

• Proficient in Microsoft Office
• Epic experience preferred