Medication Prior Authorization Specialist
Sheridan Memorial Hospital, Sheridan, WY, United States
Sheridan Memorial Hospital is a top‑ranked U.S. hospital located in northern Wyoming, offering patient‑centered care and a collaborative culture.
Job Summary
The Medication / Procedure Prior Authorization Specialist validates patient health care benefits and obtains authorization for medications, equipment, and procedures. Responsibilities include contacting insurance companies or third‑party processors to verify coverage, initiate authorizations, provide clinical documentation, follow up on pending authorizations, and respond to inquiries using multiple communication methods.
Essential Duties & Responsibilities
Obtains pre‑authorizations/pre‑certifications per payer requirements for services and ensures authorization information is documented appropriately.
Verifies physician orders are complete and determines CPT, HCPCS, and ICD‑10 codes for proper authorization.
Communicates insurance co‑pays, deductibles, co‑insurances, and out‑of‑pocket expenses for point‑of‑service collections.
Maintains communication with providers, clinical staff, and patients regarding authorization status.
Stays current with insurance requirements for pre‑authorization and provides education within departments and clinics on changes.
Keeps informed of changes in the authorization process and insurance policies.
Aids team members in maintaining turnaround times.
Accounts for internal control responsibilities in line with department objectives.
Handles Protected Health Information in compliance with HIPAA.
Performs other duties as assigned by the supervisor or manager.
Answers questions and offers information 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
High school graduate or equivalent.
Knowledge of CPT, HCPCS, and ICD‑10 codes (preferred).
Medical terminology knowledge.
Certified Pharmacy Technician preferred.
3‑5 years of experience in a hospital, doctor’s office, or pharmacy setting.
1‑2 years of procedure and/or medication authorization experience.
Additional Skills
Working knowledge of CPT codes and diagnostic codes.
Understanding of financial responsibility from an insurance perspective.
Effective presentation and communication skills with providers, clinical staff, payors, and patients.
Problem solving with limited standardization.
Ability to interpret written, oral, or scheduled instructions.
Proficient with MS Office Suite, Word, and Excel.
Proficient with Cerner EMR system.
Conflict resolution skills.
Excellent time management and organizational skills with attention to detail.
Demonstrates critical thinking, creativity, and problem solving.
Maintains confidentiality.
Clear and informative writing.
Resilience under stress and professional demeanor.
Judgment to handle situations appropriately.
Research skills for additional information or guidance.
Multitasking across systems and multiple monitors.
Independent research and utilization of online resources and tools.
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 considers all qualified applicants regardless of race, color, religion, age, sex, national origin, disability, or veteran status. You are entitled to EEO rights as an applicant under the law.
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Job Summary
The Medication / Procedure Prior Authorization Specialist validates patient health care benefits and obtains authorization for medications, equipment, and procedures. Responsibilities include contacting insurance companies or third‑party processors to verify coverage, initiate authorizations, provide clinical documentation, follow up on pending authorizations, and respond to inquiries using multiple communication methods.
Essential Duties & Responsibilities
Obtains pre‑authorizations/pre‑certifications per payer requirements for services and ensures authorization information is documented appropriately.
Verifies physician orders are complete and determines CPT, HCPCS, and ICD‑10 codes for proper authorization.
Communicates insurance co‑pays, deductibles, co‑insurances, and out‑of‑pocket expenses for point‑of‑service collections.
Maintains communication with providers, clinical staff, and patients regarding authorization status.
Stays current with insurance requirements for pre‑authorization and provides education within departments and clinics on changes.
Keeps informed of changes in the authorization process and insurance policies.
Aids team members in maintaining turnaround times.
Accounts for internal control responsibilities in line with department objectives.
Handles Protected Health Information in compliance with HIPAA.
Performs other duties as assigned by the supervisor or manager.
Answers questions and offers information 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
High school graduate or equivalent.
Knowledge of CPT, HCPCS, and ICD‑10 codes (preferred).
Medical terminology knowledge.
Certified Pharmacy Technician preferred.
3‑5 years of experience in a hospital, doctor’s office, or pharmacy setting.
1‑2 years of procedure and/or medication authorization experience.
Additional Skills
Working knowledge of CPT codes and diagnostic codes.
Understanding of financial responsibility from an insurance perspective.
Effective presentation and communication skills with providers, clinical staff, payors, and patients.
Problem solving with limited standardization.
Ability to interpret written, oral, or scheduled instructions.
Proficient with MS Office Suite, Word, and Excel.
Proficient with Cerner EMR system.
Conflict resolution skills.
Excellent time management and organizational skills with attention to detail.
Demonstrates critical thinking, creativity, and problem solving.
Maintains confidentiality.
Clear and informative writing.
Resilience under stress and professional demeanor.
Judgment to handle situations appropriately.
Research skills for additional information or guidance.
Multitasking across systems and multiple monitors.
Independent research and utilization of online resources and tools.
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 considers all qualified applicants regardless of race, color, religion, age, sex, national origin, disability, or veteran status. You are entitled to EEO rights as an applicant under the law.
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