Prior Authorization Specialist

Job Summary:

The Prior Authorization Specialist is responsible for coordinating, prioritizing, and monitoring the day-to-day operational activities of verifying insurance benefits as it applies to obtaining precertification/preauthorization from payers for specialty medications, in-clinic procedures, podiatry orthotics, surgery, pain management injections, high tech radiology (MRI, CT, Echo, Nuc Med), home and in-lab sleep studies, behavioral health visits and testing, inpatient/observation admissions, and physical/occupational/speech/cardiac rehab.

Essential Duties and Responsibilities:

1. Prepares, organizes, prioritizes, documents and communicates all necessary paperwork and information needed by insurance companies for the prior authorization process.

• Verifies provider orders, patient eligibility and submission process per payer
• Completes tasks independently in a timely manner for prior authorization
• Minimal denials due to prior authorizations accuracy
• Serves as a resource and liaison for staff and patient

2. Pursues and maintains a strong working relationship with all payer groups

• Continuously researches and stays updated on payer requirements for prior authorization
• Shares information with appropriate staff
• Updates tip sheets when appropriate

3. Verifies benefits, including medical necessity and communicates finding with appropriate department and/or patient. Acts as a resource and liaison to staff and patient regarding medical necessity and prior authorization issues

• Ensures all necessary information regarding prior authorization is documented in Epic appropriately
• Responds to patient concerns and questions timely and insures understanding
• Works collaboratively with all departments to resolve concerns and questions 

* While this job description is intended to be an accurate reflection of the job requirements, management reserves the right to modify, add or remove duties from particular jobs and to assign other duties as necessary.

Education & Licensure:

• High School diploma/GED

Experience:

• 3+ years of Medical Customer Service OR 2+ years of experience in healthcare with insurance and/or prior authorization required
• Previous experience working with insurance and third party payers preferred
• Previous experience with CPT and ICD-10 coding required
• Formal coursework in medical terminology OR previous experience with medical terminology required 
• Prior recent EPIC/Excellian experience preferred  

Knowledge, Skills & Abilities:

• Excellent communication and listening skills
• Demonstrated ability to work independently with little direction and manage multiple demands and priorities

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Prolonged periods of standing, bending, and reaching
• Must be able to lift up to 15 pounds at times

St. Croix Health is an Equal Opportunity Employer. We will ensure that persons with disabilities are provided reasonable accommodations for the hiring process. If reasonable accommodation is needed, please contact us at [email protected] or 800-828-3627.

St. Croix Health has been a healing force in the St. Croix Valley for over 103 years. We are a purpose-driven organization with a dedicated team committed to serving our patients and communities throughout the St. Croix Valley. This commitment is rooted in our mission, vision and values. 

Mission:  We help people live healthier, happier, and longer lives.              

Vision:  To transform from quality sick care to quality well care that is sustainable and affordable. 

Values:  People Centered, Trust, Innovation, and Growth. 

Here at St. Croix Health we offer our employees with a robust benefits package that includes: 

• Health, vision and dental insurance
• 403b retirement program with employer match
• Paid time off
• Short-term disability, long-term disability and life insurance options
• Education reimbursement
• Employee assistance program (EAP)
• Wellbeing incentive program
• Free parking
• Employee prescription discount program

St. Croix Health is a not-for-profit healthcare system located in St. Croix Falls, WI dedicated to helping people live healthier, happier, and longer lives. St. Croix Health offers the services of 80+ providers and 20 specialties with five community clinics in Minnesota and Wisconsin all supported by a critical access hospital on the main campus in St. Croix Falls, just an hour northeast of Minneapolis/St. Paul. Nestled in the bluffs of the St. Croix River Valley, St. Croix Falls is the ideal place to work, live and play.