Kenosha, WI
8 days ago
Prior Authorization/Referral Specialist

Position Purpose: 

A Pre-Authorization/Referral Specialist is responsible for determining insurance eligibility/benefits and ensuring pre-certification (authorization/referral) requirements are met for both the facility and professional services. The Pre-Authorization/Referral Specialist provides detailed documentation and communication with both payors and clinicians to obtain prior-authorizations. Obtains clinical information to support medical necessity.

Knowledge, Skills & Abilities required:

Experience in pre-authorization/referrals, patient registration, insurance verification and health insurance plans Knowledge of online insurance pre-authorization process and working with various payors Excellent computer and customer service skills  Familiarity with Medical Terminology  Demonstrated ability to efficiently organize work, while maintaining a high level of accuracy and productivity  Knowledge of ICD-10, CPT and HCPC codes and use Familiarity with internet, email and Microsoft Office Effective written and verbal communication skills required

 

Principal Accountabilities and Essential Duties of the Job:

Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services Obtains pre-certification, authorization and referral approval for required services for both the facility and professional services. Calculates “billable units” for medication as identified by the payer rather than utilizing patient visits. Coordinates and supplies information to the review organization (payer) including clinical information and/or letter of medical necessity for determination of benefits.  Coordinates peer-to-peer review, when required. Communicates with patients, clinicians, financial counselors and others as necessary to facilitate authorization process.   Completes accurate documentation in the healthcare software Completes inpatient notification to all payers using their preferred method within 24 hours of admission  Ensures timely and accurate insurance authorizations/referrals are in place prior to services being rendered Notifies patient/department when authorization/referral has not been obtained prior to service date 

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