Job Information
Froedtert South Prior Authorization/Referral Specialist in Kenosha, United States
Prior Authorization/Referral Specialist
Froedtert South Kenosha, WI (Onsite) Full-Time
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Job Details
POSITION PURPOSE
A Prior-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 Prior-Authorization/Referral Specialist provides detailed documentation and communication with both payors and clinicians to obtain prior-authorizations
Obtains clinical information to support medical necessity.
MINIMUM EDUCATION REQUIRED
High School or GED
MINIMUM EXPERIENCE REQUIRED
1-3 years
LICENSES / CERTIFICATIONS REQUIRED
Formal education beyond high school in Business or Healthcare or equivalent experience preferred.
KNOWLEDGE, SKILLS & ABILITIES REQUIRED
Experience in prior authorization/referrals, patient registration, insurance verification and health insurance plans.
Knowledge on online insurance prior-authorization process and working with various payors.
Excellent customer service and computer 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.
PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES
Verifies 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.
Manages and resolves assigned departmental workqueues.
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 reviews, when required.
Communicates with patients, clinicians, financial counselors and other as necessary to facilitate the authorization process.
Completes accurate documentation in 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.
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.
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Job Snapshot
Job Type Business/Office/Clerical
Schedule Full-time
Shift Days
Hours 80
Facility/Name Froedtert Kenosha Center