Prior Authorization/Referral Specialist

FroedtertSouth•Pleasant Prairie, WI

4d•$17 - $25

About The Position

POSITION PURPOSE The Prior-Authorization/Referral Specialist plays a key role in supporting patient access to care by verifying insurance eligibility and benefits, and securing required pre-certifications, authorizations, and referrals for both facility and professional services. This position ensures timely and accurate communication with payors and healthcare providers, obtains necessary clinical documentation to support medical necessity, and maintains detailed records throughout the authorization process.

Requirements

High School or GED
One (1) year of insurance/prior authorization experience (preferred)
Experience and familiarity with using insurance portals
Strong customer service orientation with excellent interpersonal and computer skills.
Working knowledge of medical terminology and healthcare documentation standards.
Demonstrated ability to manage time effectively, prioritize tasks, and maintain accuracy in a high-volume environment.
Proficient with internet-based tools, email communication, and Microsoft Office applications (e.g., Word, Excel, Outlook).
Strong written and verbal communication skills, with the ability to interact professionally with patients, clinicians, and insurance representatives.

Nice To Haves

Proven experience in prior authorizations, referrals, patient registration, insurance verification, and understanding of various health insurance plans (preferred).
Proficient in navigating online prior authorization portals and working with multiple commercial and government payors (preferred).
Knowledge of medical coding systems, including ICD-10, CPT, and HCPCS codes (preferred).

Responsibilities

Verify insurance eligibility and benefits for scheduled services to determine prior-authorization or referral requirements.
Initiate and follow through on prior-authorization and referral requests with payors, ensuring timely approvals.
Collect and submit required clinical documentation to support medical necessity and facilitate authorization.
Document all authorization activities accurately in the electronic health record (EHR) and/or designated tracking systems.
Communicate authorization status and requirements clearly to providers, clinical staff, and patients as needed.
Coordinate with providers and clinical teams to obtain additional information or clarification required by payors.
Maintain up-to-date knowledge of payer policies, coding guidelines (ICD-10, CPT, HCPCS), and authorization processes.
Ensure timely resolution of authorization-related issues to prevent delays or denials in patient care or billing.
Provide exceptional customer service when interacting with internal teams, external payors, and patients.
Participate in continuous quality improvement efforts, including audits, training, and performance reviews.