Pre-authorization Specialist (Full-Time, M-F)

Organization Overview, Mission, Vision, and Values

Our mission is to improve the health of people in the communities we serve through compassionate, high-quality care, prevention, and wellness education. Washington Regional Medical System is a community-owned, locally governed, non-profit health care system located in Northwest Arkansas in the heart of Fayetteville, which is consistently ranked among the Best Places to live in the country. Our 425-bed medical center has been named the #1 hospital in Arkansas for four consecutive years by U.S. News & World Report. We employ 3,400 team members and serve the region with over 45 clinic locations, the areas only Level II trauma center, and five Centers of Excellence - the Washington Regional J.B. Hunt Transport Services Neuroscience Institute; Washington Regional Walker Heart Institute; Washington Regional Women and Infants Center; Washington Regional Total Joint Center; and Washington Regional Pat Walker Center for Seniors.

Position Summary

The Pre-authorization Specialist reports to the Clinic Manager. This position is responsible for obtaining and processing prior authorization requests for treatments, procedures, or medications, ensuring compliance with insurance policies and facilitating patient access to necessary care. This position must have strong organizational skills, attention to detail, and the ability to work with both healthcare providers and insurance companies.

Essential Position Responsibilities

• Review medical records and necessity criteria.
• Gather necessary information and documentation from healthcare providers and patients.
• Submit authorization requests to insurance companies, following their specific procedures.
• Track the status of authorization requests and follow up as needed.
• Verify patient insurance coverage and eligibility.
• Develop knowledge for different insurance plans, policies, and procedures.
• Ensure that services and medications are covered by the patient's plan.
• Identify and address potential denials.
• Appeal denials when appropriate, providing necessary documentation.
• Collaborate with providers to find alternative solutions.
• Communicate with healthcare providers, patients, and insurance companies.
• Explain complex insurance procedures to patients in a clear and concise manner.
• Maintain accurate and up-to-date records of authorization requests and related activities.
• Ensure compliance with relevant regulations and policies.
• Provide administrative support to other departments as needed.

Qualifications

• Education: High School Diploma or GED, required.
• Licensure and Certifications: N/A
• Experience: Previous experience within a healthcare setting preferred.

Professional Skills

• Strong communication skills.
• Knowledge of insurance policies and procedures.
• Ability to review medical records and documentation.
• Strong organizational and time management skills.
• Problem-solving and analytical skills.
• Proficiency in using computer systems and software.
• Understanding of healthcare terminology.

Work Environment: This position will spend 80% of time sitting while performing work in a standard office environment. This position will spend 20% of time standing and/or walking while pushing, pulling, lifting, and/or carrying up to 50 lbs.

Notice: This job description is designed to provide an overview of the essential and principal duties and responsibilities of the position. The job description is not designed or intended to cover or set forth a comprehensive listing of all activities, duties or responsibilities that are required of the employee. Washington Regional reserves the right in its absolute discretion to change duties, responsibilities or activities or assign new duties, responsibilities, or activities at any time with or without notice. Employees may be directed to perform job-related tasks other than those specifically presented in this description.