Prior Authorization Specialist

As the Pre/Prior Authorization Specialist, this position is responsible for verifying patient insurance eligibility, coverage, and benefits and for securing all required pre-certifications and prior authorizations from third-party payers before scheduled services are rendered across all areas of Weston County Health Services (WCHS), including the hospital, the Manor skilled nursing facility, and the outpatient clinics. This position ensures each patient's authorization requirements are resolved in advance of treatment in order to support financial clearance, reduce avoidable denials, and promote a positive patient experience.

This position reports directly to the Chief Financial Officer.

• Promotes the mission, vision, and values of Weston County Health Services (WCHS).
• Completes accurate and timely verification of patient insurance eligibility, coverage, and benefits prior to scheduled services.
• Determines pre-certification and prior authorization requirements for scheduled services across all WCHS departments and service lines.
• Obtains and secures required authorizations, pre-certifications, and referrals from third-party payers before services are rendered.
• Ensures all necessary data elements for an authorization (e.g., CPT codes, diagnosis codes, and supporting clinical documentation) are available and submitted with each request.
• Ensures services scheduled by outside providers have approved authorization as required by the payer and procedure prior to service.
• Enters authorization numbers, approval codes, and related information accurately into the registration and patient accounting system.
• Verifies that physician orders are present and attached to the patient record to ensure ordered tests and procedures are appropriate and covered.
• Communicates with patients, insurers, physician offices, ancillary departments, and other appropriate parties regarding insurance verification and authorization status.
• Escalates financial clearance risks---such as unauthorized services, coverage gaps, or self-pay and underinsured situations---as appropriate and prior to the date of service.
• Refers uninsured and underinsured patients, and point-of-service pre-payment situations, to the appropriate financial counseling or financial assistance resource to determine eligibility for assistance and to arrange payment prior to service where applicable, helping to manage the organization's bad debt.
• Notifies the appropriate hospital, Manor, or clinic staff of authorization status, authorized length of stay, and any concurrent review requirements.
• Documents all financial clearance and authorization work clearly and according to established documentation standards.
• Maintains current knowledge of payer-specific authorization requirements, timelines, and portals for Medicare, Medicaid, and commercial payers.
• Creates a positive patient experience by being polite, compassionate, and professional.
• Provides cross-coverage and training for other team members when needed.
• Maintains productivity and quality performance expectations.
• Maintains confidentiality of all patients, financial, and legal information at all times.
• Coordinates with other departments to ensure efficiency.
• Attends and participates in staff meetings and other assigned meetings.
• Adheres to accreditation and compliance standard guidelines.
• Utilizes good communication skills to maintain positive relationships with clients, providers, co-workers and other sections in the organization and with other facilities in the community.
• Maintains a professional, organized and clean working environment by following organizational policies, guidelines, and safety standards.
• Completes work assignments in a timely manner.
• Reviews and meets ongoing competency…