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Prior Authorization & Referral Specialist

UnityPoint Health Finley Hospital, Dubuque, IA

This listing has expired

Dubuque Delhi Medical Office 

FTE: 1.000000


Work hours will be days, for 80 hours per pay period and as needed. You will be required to flex to other shifts as needed.



Essential Functions and Responsibilities:

Prior Authorization and Referral Specialist supports the clinical staff and providers by working effectively with insurance companies to obtain prior authorization for diagnostic testing and procedures.  This position will also be responsible for coordinating and completing referrals ordered by Clinicians.

Responsibilities include:

·       Insurance verification

·       Obtains prior authorizations as required by payer source, including procurement of needed documentation by collaborating with Clinical Care Team and Insurance carrier.  Obtain all authorizations via phone, web or fax.

·       Performs chart review/abstraction to obtain necessary documentation to complete pre-authorization/pre-certification of test/procedure/service.

·       Obtaining and arranging referral appointments, keeping UnityPoint Health system as a top referral source

·       Notify proper clinic personnel of any issues with insurance verification or authorizations.

·       Keep up to date on insurance policies regarding coverage and prior authorizations.

·       Follow up daily on outstanding and pending authorizations.

·       Communicates effectively with physicians and clinical staff on the status of the prior authorizations

·       Uses the EMR system to document the prior authorization approval or denial; Follows up with staff or physicians accordingly.

·       Communicates effectively with other staff at outside facilities.

·       Develops a system to track prior authorizations that need follow up.

·       Communicates with patient and staff regarding patient assistance programs.

·       Coordinates with medical staff, payers, physicians, and patients regarding authorization status and options.

·       Maintains current referral policies and procedures, payer requirements and managed Care plans In/Out of Network.

·       Initiate, follow up, and verify insurance eligibility for services provided and document complete information in Epic.

·       Assist patient with finding resources that accept various insurances, when processing Outgoing/External referrals.

·       Determines patient's financial responsibilities as indicated by insurance carrier.

·       Configures coordination of benefit information and eligibility on every referral.

·       Collects any clinical information such as lab values, encounters, and diagnosis codes as needed.

·       Documents all pertinent communication with patient, physician, and insurance company as it will be a viable source in support of requested services.

·       Reviews and manages Epic Work queues and other information pathways to maintain accurate authorization requests.

·       Schedules appointments as appropriate within required timeframes.

·       Serves as a resource liaison with referral / appointment inquiries from patients, clinical care teams, and other staff.

·       Assists providers with peer to peer review; suppling documentation, scheduling of call and follow-up.

·       Tracks denials for no precertification/authorization to find root cause and prevent denial in the future

·        Assists with appeals for services that the insurance carrier deems as not authorized/pre-certified or notification was not completed.

·       For services the provider deems as medically necessary and insurance will not authorize or approves; explains option to the patient including financial obligation out of pocket or deferral of service recommendation.

·       Makes recommendations for documentation templates to insure patient records meet documentation requirements of the insurance plans. 

·       Work independently and responsible for timely completion of assigned functions.

·       Be aware of what is happening in clinic/department and the organization by attending clinic/department meetings, reading emails and regularly checking information on the organization’s intranet site.

·       Maintain regular and consistent attendance at work.

·       Maintain compliance with CLIA, OSHA, Safety and Risk Management guidelines.

·       Maintain compliance with Personnel policies and procedures.

·       Monitor environmental conditions in order to secure protected health information.

·       Behave in a manner consistent with all Corporate Compliance and HIPAApolicies and procedures.

·       Demonstrate initiative to improve quality and customer service by striving to exceed customer expectations.

·       Balance team and individual responsibilities; be open and objective to other’s views; give and welcome feedback; contribute to positive team goals; and put the success of the team above own interests.

·       Perform other duties as requested by Revenue Cycle Manager to facilitate the smooth and effective operations of the position.


Supervision Received:

·       General supervision is received from the Revenue Cycle Manager.




·       1-2 years of previous medical office experience utilizing medical terminology and prior authorization experience is preferred

·       Basic knowledge of Microsoft Office required

·       Previous experience with an electronic health record or medical office software required

·       Previous experience coding diagnoses and procedures with ICD-10-CM and CPT preferred

·       CMA or LPN preferred

·       Mandatory Reporter certification.

·       Ability to demonstrate strong customer service skills.

·       Ability to effectively enter information into a variety of computer programs, to include insurance websites and electronic work queues. 

·       Ability to understand and apply guidelines, policies and procedures.

·       Ability to interact effectively with patients, physicians, health care team members, and members of other support systems.

·       Ability to communicate effectively with people of diverse professional, educational and lifestyle backgrounds..

·       Strong interpersonal skills.

·       Strong computer skills.

·       Ability to work as a team member.

·       Strong verbal and written communication skills. 







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Job Details

Req Num 22904
ID 372205
Dubuque, IA
Positions 1
Pay --
Environmental/Quality Assurance/Safety
Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
Retirement Plan
Paid Vacation
Paid Sick Leave
Paid Holidays
Tuition Reimbursement

Preferred Candidates

Years of Experience --
Education --

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