Prior Authorization Specialist: Elevate Patient Access

UP Health System – Portage; Hancock Township (MI); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

Comprehensive benefits

Paid time off and disability coverage

Tuition assistance for education/cert

401(k) retirement plan with company-m

Wellness programs

Career development opportunities

Job summary

UP Health System - Portage is seeking a detail-oriented Prior Authorization Specialist to manage pre-certifications and payer communications. You will coordinate with physicians, patients, and insurers to obtain authorizations and ensure timely, accurate processing of cases.

The role requires knowledge of Medicare/Medicaid and third-party payer requirements, with a focus on minimizing delays and denials while educating staff and providers about referral and authorization processes.

Qualifications

• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• High School Diploma or Equivalent required.

Responsibilities

• Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients.
• Follows up with physician offices, financial counselors, patients, and third-party payers to complete the pre-certification process.
• Collaborates with Supervisor, internal departments and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.
• Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
• Educates patients, staff and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.
• Ensures all services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance.
• Notifies patient accounts staff/patients of insurance coverage lapses, and self-pay patient status.
• May notify ordering providers if authorization/certification is denied.
• May coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.
• Maintains files for referral and insurance information and enters referrals into the system.
• Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
• Serves as an expert for peers across the patient access continuum.
• Meets daily productivity and quality standards associated with job requirements.

Skills

Critical thinking

Decisive judgment

Work independently

Education

High School Diploma or Equivalent

Job description

UP Health System - Portage is seeking a detail-oriented Prior Authorization Specialist to manage pre-certifications and payer communications. You will coordinate with physicians, patients, and insurers to obtain authorizations and ensure timely, accurate processing of cases.

The role requires knowledge of Medicare/Medicaid and third-party payer requirements, with a focus on minimizing delays and denials while educating staff and providers about referral and authorization processes.