Medication Prior Authorization Specialist

SHERIDAN MEMORIAL HOSPITAL

At Sheridan Memorial Hospital, we proudly rank in the top 13.6% of U.S. hospitals, recognized by the Centers for Medicare and Medicaid Services. With over 850 dedicated employees and 100+ expert providers across 25 specialties, we are committed to exceptional, patient-centered care. Set in northern Wyoming’s stunning Big Horn Mountain foothills, Sheridan offers outdoor adventure and community charm. Our hospital combines cutting-edge technology with a collaborative, innovative culture. Join a team that values your skills, fosters growth, and empowers you to impact lives meaningfully. Apply today and be part of Sheridan Memorial Hospital’s mission of excellence!

JOB SUMMARY

The Medication / Procedure Prior Authorization Specialist is a health care professional working to validate the patients’ health care benefits and obtain authorization for medications, equipment and procedures. Responsibilities include contacting a patient’s insurance company or using third party companies to verify coverage, initiate authorizations, provide clinical documentation, follow up on previously initiated authorizations. Also, responsible for responding to inquiries using multiple methods of communications.

ESSENTIAL DUTIES / RESPONSIBILITIES

• Obtains pre-authorizations/pre-certification per payer requirements for services and ensures authorization information is documented appropriately.


• Verifies physician orders are complete, determines CPT, HCPCS and ICD-10 codes for proper authorization.


• Ability to understand and communicate insurance co-pays, deductibles, co-insurances, and out-of-pocket expenses for point of service collections.


• Communication is maintained with providers, clinical staff, and patients in relationship to authorization status.


• Remains current with insurance requirements for pre-authorization and provides education within the departments and clinics on changes.


• Keep informed of changes in the authorization process and insurance policies.


• Aid team members in maintaining turnaround times.


• Account for internal control responsibilities in line with the department objectives.


• Ability to handle Protected Health Information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPAA)


• Other duties as assigned by the supervisor or manager


• Answer questions and offer other information, as requested, to provide patient-focused service and a positive impression of the organization.


• Suggests improvements and participates in organized efforts to improve service levels

POSITION QUALIFICATIONS

Education, Experience & License

• High school graduate or equivalent, required.


• Knowledge of CPT, HCPCS, and ICD-10 codes preferred.


• Medical terminology required.


• Certified Pharmacy tech, preferred


• 3-5 years of experience working in a hospital, doctors office, or pharmacy setting


• 1-2 years procedure and/or medication authorization experience required.

Additional Skills

• Have working knowledge of CPT codes and Diagnostic Codes


• Working knowledge of financial responsibility from an insurance perspective


• Ability to effectively present information and respond to questions from providers, clinical staff, payors, and patients.


• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.


• Ability to interpret a variety of instructions furnished in written, oral, or scheduled form.


• Proficient with MS Office Suite including Word, and Excel.


• Proficient with the Cerner EMR system.


• Ability to solve conflict.


• Must possess excellent time management and organization skills with attention to detail.


• Demonstrates critical thinking, creativity, and problem solving.


• Demonstrates the ability to maintain confidentiality.


• Ability to write clearly and informatively.


• Ability to cope with stressful situations and maintain a calm and professional demeanor.


• Ability to exercise good judgment to handle situations appropriately


• Ability to use online resources to and tools to achieve goals in the most efficient manner


• Ability to multi-task using several systems and multiple monitors at the same time


• Ability to independently and effectively research when additional information or guidance is needed.
  
  

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products.

Pre-employment drug and alcohol screening is required.

Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer and gives consideration for employment to qualified applicants without regard to race, color, religion, age, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights as an applicant under the law, please click here.