Prior Authorization Nurse Jobs (NOW HIRING)

Join our team as a Prior Authorization Specialist! Are you detail-oriented, organized, and passionate about helping patients access the care they need? WCHS is seeking a FT Prior Authorization Specialist to support our team by coordinating insurance authorizations and helping ensure services are approved and delivered efficiently. This is an exciting opportunity to get your foot in the door and start a career with WCHS in this newly created position.

Compensation: Negotiable, depending on experience

Job Summary

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.

Essential Functions

• 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 patient, 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 requirements of the role to maintain the skills, knowledge, and abilities to perform role-specific functions within scope.
• Enhances professional growth and development through participation in educational programs, trainings, current literature, in-service meetings and workshops; shows responsibility for own professional practice and ongoing education and learning.
• Performs other duties as assigned.

Additional Requirements

• Adheres to dress code, appearance is neat and clean.
• Completes annual education requirements.
• Maintains confidentiality at all times.
• Reports to work on time and as scheduled.
• Wears identification badge while on duty.
• Maintains regulatory requirements, including all state, federal, and local regulations.
• May not at any time be excluded from participation in any federally funded program, including Medicare and Medicaid; must immediately notify management or the Compliance Officer if threatened with or subject to such exclusion.
• Represents WCHS in a positive and professional manner at all times.
• Complies with all WCHS policies and standards regarding ethical business practices.
• Communicates the mission, ethics, and goals of WCHS.
• Participates in performance improvement and continuous quality improvement activities.
• Attends regular staff meetings and in-services.
• Excellent verbal and written communication skills.
• Excellent interpersonal, negotiation, and conflict resolution skills.
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Strong analytical and problem-solving skills.
• Has the ability to prioritize tasks and to delegate them when appropriate.
• Has the ability to act with integrity, professionalism, and confidentiality.

Qualifications

• High School Diploma or equivalent.
• Two years' experience in a medical business office, patient registration, or health care setting involving insurance verification, authorization, or patient-facing customer service, or an equivalent combination of education and experience.
• Working knowledge of insurance eligibility, benefits, pre-certification, and prior authorization processes for Medicare, Medicaid, and commercial payers.
• Completion of post-secondary coursework in medical terminology and CPT/diagnosis coding, or graduation from a medical assistant, health unit coordinator, or health care business services program, preferred.
• Proficiency with electronic health record and patient registration/accounting systems.
• Good math skills and the ability to spot numerical errors.
• Strong written and oral communication skills.

Knowledge, Skills, and Abilities

• Strong organizational and interpersonal skills.
• Knowledge of insurance verification, pre-certification, and prior authorization requirements and workflows.
• Has the ability to determine an appropriate course of action in more complex situations.
• Has the ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude.
• Has the ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
• Has the ability to perform basic mathematical calculations and to balance and reconcile figures accurately.
• Has the ability to maintain confidentiality of all medical, financial, and legal information.
• Has the ability to complete work assignments accurately and in a timely manner.
• Has the ability to communicate effectively, both orally and in writing.
• Has the ability to handle difficult situations involving patients, physicians, payers, or others in a professional manner.

Physical Requirements and Environmental Conditions

• Prolonged periods of sitting at a desk and working on a computer.
• Occasional after-hours calls may occur.
• Must be able to access, find, and navigate each department at WCHS.
• Position requires light to moderate work with 50 pounds maximum weight to lift and carry.
• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing.

"Weston County Health Services is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status."