**Wisconsin and Michigan residents only eligible to apply**
SEE BELOW for Additional Job Summary, Key Responsibilities, and Required Skills and Qualifications
JOB SUMMARY
The Authorization Specialists are responsible for verifying patient insurance eligibility and coverage and securing third party payer authorization for services to be rendered.
JOB QUALIFICATIONS
EDUCATION
For positions requiring education beyond a high school diploma or equivalent, educational qualifications must be from an institution whose accreditation is recognized by the Council for Higher Education and Accreditation.
Minimum Required: None.
Preferred/Optional: Successful completion of post-secondary courses in Medical Terminology and Diagnosis and CPT Coding, and Anatomy & Physiology. Graduate of a Medical Assistant, Health Unit Coordinator, or Health Care Business Service program.
EXPERIENCE
Minimum Required: Two years’ experience in a medical business office or healthcare setting involving customer service or patient-facing responsibilities, or equivalent experience.
Preferred/Optional: None.
CERTIFICATIONS/LICENSES
The following licensure(s), certification(s), registration(s), etc., are required for this position. Licenses with restrictions are subject to review to determine if restrictions are substantially related to the position.
Minimum Required: None.
Preferred/Optional: None.
Additional Job Summary
An Authorization Specialist is a healthcare professional responsible for reviewing patient medical records to determine if a prescribed treatment, procedure, or medication requires prior authorization from the insurance company, ensuring that the requested care is deemed medically necessary and covered under the patient's benefits before it can be administered; this involves verifying patient eligibility, contacting insurance companies to obtain authorization, and managing the process to minimize delays in patient care. An Authorization Specialist works in a fast-paced environment with high call volumes, requiring strong organizational skills and the ability to manage multiple tasks simultaneously.
Key Responsibilities
Reviewing patient records:
Carefully examine medical records to assess if a proposed treatment or medication needs prior authorization based on insurance guidelines and medical necessity criteria.
Benefit verification:
Confirm patient insurance coverage, including eligibility, and any prior authorization requirements.
Contacting insurance companies:
Initiate contact with insurance payers to submit prior authorization requests, providing necessary clinical information to support the medical necessity of the requested care.
Follow-up communication:
Monitor the status of prior authorization requests, communicate with providers and patients regarding any necessary information updates, and address any denials or appeals.
Data entry and recordkeeping:
Accurately document all prior authorization activities, including patient details, insurance information, and the status of each request within the electronic health record system.
Required Skills and Qualifications
Medical knowledge:
Understanding of basic medical terminology, disease processes, and treatment options to accurately assess medical necessity.
Insurance knowledge:
Familiarity with different insurance plans, benefit structures, and prior authorization guidelines.
Excellent communication skills:
Ability to effectively communicate with healthcare providers, insurance companies, and patients to clarify information and address concerns.
Attention to detail:
High level of accuracy in data entry and review of medical records to ensure correct prior authorization requests.
Problem-solving skills:
Ability to identify potential issues with prior authorization requests, navigate complex situations, and find solutions to ensure timely patient care.
Marshfield Clinic Health System is committed to enriching the lives of others through accessible, affordable and compassionate healthcare. Successful applicants will listen, serve and put the needs of patients and customers first.
At Marshfield Clinic Health System, we are fully committed to addressing health equity, diversity and inclusion for our employees and providers, our patients, and the communities we serve. We believe that every individual should have the opportunity to attain their highest level of health. We embrace diversity and welcome differences in who we are and how we think. We believe that any individual or group should feel welcomed, respected and valued. View our Equity and Inclusion Statement here.Exclusion From Federal Programs: Employee may not at any time have been or be excluded from participation in any federally funded program, including Medicare and Medicaid. This is a condition of employment. Employee must immediately notify his/her manager or the Health System’s Compliance Officer if he/she is threatened with exclusion or becomes excluded from any federally funded program.
Marshfield Clinic Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.