Demo

Prior Authorization/Referral Specialist

Froedtert South, Inc.
Kenosha, WI Full Time
POSTED ON 3/12/2025
AVAILABLE BEFORE 5/11/2025

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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