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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Froedtert South is a comprehensive regional healthcare system that has served southeastern Wisconsin and northern Illinois communities for more than 100 years. Froedtert South provides services primarily through the Froedtert Kenosha Hospital and the Froedtert Pleasant Prairie Hospital and several other clinic locations.

Froedtert South is an Equal Opportunity Employer. Froedtert South does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment decisions are made on the basis of qualifications, merit, and business need.