Prior Authorization Specialist

Talentify; Sheridan (WY); On-site; USD 42,000 - 56,000; Full time

Job summary

Sheridan Memorial Hospital is seeking a Medication / Procedure Prior Authorization Specialist to verify benefits and obtain required approvals for medications and procedures. You will contact insurers, provide documentation, and support clinicians and patients throughout the authorization process.

The role requires knowledge of CPT/HCPCS/ICD-10 coding, strong communication skills, and experience in a hospital or billing environment. Minimum 3–5 years preferred; HIPAA compliance is essential.

Qualifications

• High school diploma or equivalent is required.
• Knowledge of CPT, HCPCS, and ICD-10 codes preferred.
• Medical terminology is required.
• 3–5 years in a hospital, clinic, or billing setting.

Responsibilities

• Obtain pre-authorizations/pre-certification per payer requirements.
• Determine CPT, HCPCS and ICD-10 codes for authorizations.
• Explain insurance co-pays, deductibles, and out-of-pocket costs.
• Communicate authorization status with providers, staff, and patients.
• Assist billing with researching denied claims and follow-up.

Skills

Communication

Teamwork

Customer service

Attention to detail

Problem solving

Time management

Education

High school diploma

Medical terminology

CPT/HCPCS/ICD-10 knowledge

Hospital billing experience

Tools

EMR system

MS Office

Job description

ABOUT SHERIDAN MEMORIAL HOSPITAL

Sheridan Memorial Hospital is a progressive, state-of-the-art facility nestled beneath the Big Horn Mountains in beautiful Northeast Wyoming. Founded over 100 years ago, Sheridan Memorial is licensed for 88 beds with over 60 physicians who provide primary medical care and specialty care in more than 15 areas. We are proud of our more than 700 employees who provide personalized, patient-centered care in a healing environment. When people think of excellent healthcare, they think of Sheridan.

JOB SUMMARY

The Medication / Procedure Prior Authorization Specialist is a health care professional working to validate the patients’ health care benefits and obtain authorization for scheduled medications and potentially urgently needed office procedures. Responsibilities include contacting a patient’s insurance company to verify coverage, initiate authorizations, provide clinical documentation, and follow up on previously initiated authorizations. Serves as a valued member of the health care team, helping patients get the medical procedures they need. Also, responsible for responding to telephone/email inquiries from callers as they relate to health services our customers provide.

ESSENTIAL JOB FUNCTIONS

• Obtains pre-authorizations/pre-certification per payer requirements for services rendered and ensures authorization information is documented appropriately in the system.
• Verifies physician orders are accurate, determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization.
• Ability to understand and communicate insurance co-pays, deductibles, co-insurances, and out-of-pocket expenses for point of service collections.
• Communication is maintained with providers, clinical staff, and patient in relationship to authorization status.
• Works and assists with the billing department in researching and resolving rejected, incorrectly paid and denied claims as requested.
• Helps to maintain a professional atmosphere for patients, family members and staff.
• Remains current with insurance requirements for pre-authorization and provides education within the departments and clinics on changes.
• Keep management informed of changes in authorization process, insurance policies, billing requirements, rejection or denial codes as they pertain to claim processing and coding.
• Ability to demonstrate good customer service (AIDET)
• Aid team members in maintaining turnaround times as expected from client
• Account for internal control responsibilities in line with the organization’s objectives
• Ability to handle Protected Health Information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA)
• Other duties as assigned by supervisor or manager
• Answer questions and offer other information, as requested, to provide patient-focused service and a positive impression of the organization
• Suggests improvements and participates in organized efforts to improve service levels

POSITION QUALIFICATIONS

Education / Experience / License and Certifications

• High school graduate or equivalent.
• Knowledge of CPT, HCPCS, and ICD-10 codes preferred.
• Medical terminology required.
• 3-5 years of experience working in a hospital, doctor's office, or billing setting
• Have working knowledge of CPT codes and Diagnostic Codes
• 1-2 years procedure and/or medication authorization experience required.

Additional Skills

• Ability to effectively present information and respond to questions from providers, clinical staff, payors, and patients.
• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, or scheduled form.
• Proficient with MS Office Suite including Word, Excel and PowerPoint.
• Proficient with the EMR system.
• Ability to solve conflict.
• Must possess excellent time management and organization skills with attention to detail.
• Demonstrates critical thinking, creativity, and problem-solving.
• Demonstrates the ability to maintain confidentiality.
• Ability to write clearly and informatively.
• Ability to cope with stressful situations and maintain a calm and professional demeanor.
• Ability to exercise good judgment to handle situations appropriately
• Ability to use online resources to and tools to achieve goals in the most efficient manner
• Ability to multi-task using several systems and multiple monitors at the same time

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products.

Pre-employment drug and alcohol screening is required.

Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer and gives consideration for employment to qualified applicants without regard to race, color, religion, age, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights as an applicant under the law.