OTHER

FEED

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Overview: The Insurance Pre-Authorization Specialist I is responsible for completing prior authorizations, pre-certifications, and notifications for third-party and government payers across all pre-scheduled elective inpatient admissions, direct admits, emergency room admissions, and outpatient procedures. Identifies, reviews, and processes pre-authorizations, pre-certifications, and notifications for Medicare, Medicaid, commercial, and managed care payers for inpatient, outpatient, emergency, and elective services.

HOUR

Min:
USD $16.50/Hr.

Max:
USD $24.82/Hr.

Overview:
<p style="margin:0px">The Insurance Pre-Authorization Specialist I is responsible for completing prior authorizations, pre-certifications, and notifications for third-party and government payers across all pre-scheduled elective inpatient admissions, direct admits, emergency room admissions, and outpatient procedures. This role requires a thorough working knowledge of insurance plans and benefit structures to obtain detailed benefit information and maximize plan utilization.</p><p style="margin:0px">The specialist coordinates with third-party payers, physicians, nursing staff, and other healthcare providers to ensure all prior authorization and pre-certification requirements are met in accordance with payer guidelines. This includes providing education and direction to clinical and administrative staff regarding authorization processes and payer-specific requirements to support accurate and timely reimbursement.</p><p style="margin:0px">This position is responsible for tracking, documenting, and monitoring authorization and pre-certification status throughout the continuum of care. The specialist also performs dynamic coding for outpatient services and urgent admissions by correlating and documenting accurate procedural and diagnosis codes based on physician orders.</p><p style="margin:0px">In addition, the role includes communicating delays, denials, or issues related to authorization determinations to clinical staff across service lines as well as to Managed Care, Utilization Management, and Patient Financial Services teams. When appropriate, the specialist may provide guidance to patients regarding appeal procedures for denied authorizations.</p><p style="margin:0px">A strong understanding of insurance and payer policy language is essential, including knowledge of benefits and authorization requirements at admission, during the hospital stay, and at discharge. This includes supporting concurrent review processes while patients are actively receiving care.</p><p style="margin:0px"> </p><p style="margin:0px"><strong>To review Memorial's Benefits click here: <a href="https://jobs.memorial.health/about/benefits/" rel="noopener nofollow noreferrer" target="_blank">Benefits - Memorial HR</a></strong></p>

Qualifications:
<h2><strong>Education</strong></h2><ul><li>High school diploma or equivalent required.</li></ul><hr/><h2><strong>Experience</strong></h2><ul><li>Minimum of three (3) years of healthcare registration, billing/claims, scheduling, or physician office experience required.</li><li>Experience with or working knowledge of call center processes preferred.</li></ul><hr/><h2><strong>Knowledge, Skills, and Abilities</strong></h2><h3><strong>Healthcare & Billing Knowledge</strong></h3><ul><li>Demonstrated working knowledge of medical terminology, procedural and diagnosis coding, and hospital billing workflows and processes required.</li><li>Awareness and understanding of healthcare industry trends and developments, including Health Care Reform, required.</li></ul><h3><strong>Technical Skills</strong></h3><ul><li>Proficiency with Microsoft Office Suite (Outlook, Excel, Word) required.</li><li>Ability to navigate multiple systems and applications, including:<ul><li>Online learning platforms for job competencies</li><li>Electronic registration and billing systems</li><li>Online forms, policies, and benefits enrollment tools</li></ul></li></ul><h3><strong>Communication & Interpersonal Skills</strong></h3><ul><li>Ability to communicate clearly and effectively, both verbally and in writing, with:<ul><li>Patients and families</li><li>Physicians and clinical staff</li><li>Payers and insurance representatives</li><li>Internal departments and leadership</li></ul></li><li>Ability to educate, persuade, and negotiate with patients/families to ensure compliance with payer requirements and collections goals.</li></ul><h3><strong>Critical Thinking & Problem Solving</strong></h3><ul><li>Ability to analyze information, problems, and workflows to identify:<ul><li>Patterns and trends</li><li>Cause-and-effect relationships</li><li>Logical conclusions and alternatives</li></ul></li><li>Ability to develop practical, comprehensive solutions.</li></ul><h3><strong>Work Performance & Adaptability</strong></h3><ul><li>Ability to remain flexible and exercise sound judgment in high-stress situations.</li><li>Capable of managing competing priorities and working independently with minimal supervision.</li><li>Demonstrated initiative and reliability in completing assignments.</li><li>Ability to adapt to changing operational needs, including staffing shortages, cross-training requirements, and departmental coverage needs.</li><li>Willingness to provide coverage and complete assignments prior to end of shift when necessary.</li></ul><h3><strong>Productivity Expectations</strong></h3><ul><li>Ability to process an average of 40–45 scheduled patient accounts/visits per day.</li></ul>

Responsibilities:
<h3>Insurance Verification, Authorization & Eligibility</h3><ul><li>Identifies, reviews, and processes pre-authorizations, pre-certifications, and notifications for Medicare, Medicaid, commercial, and managed care payers for inpatient, outpatient, emergency, and elective services.</li><li>Ensures patient eligibility requirements are met prior to service delivery.</li><li>Utilizes payer portals, internal systems, and direct communication with physician offices and third-party payers to obtain authorization and benefit information.</li><li>Analyzes patient eligibility, benefits, and reason-for-visit criteria to confirm documentation completeness and payer compliance prior to admission.</li><li>Coordinates primary, secondary, and tertiary coverage to ensure correct coordination of benefits and reduce duplicate payments or claim errors.</li></ul><hr/><h3>Medical Coding & Clinical Documentation Support</h3><ul><li>Interprets patient requisitions and assigns accurate ICD-10-CM and CPT codes in alignment with coding guidelines.</li><li>Ensures correct diagnosis and procedure code sequencing based on patient signs, symptoms, and clinical documentation.</li><li>Collaborates with HIM coding staff, physicians, and clinical teams to validate coding accuracy and resolve discrepancies.</li><li>Maintains compliance with outpatient coding standards, reimbursement rules, and regulatory requirements.</li></ul><hr/><h3>Compliance, Regulatory, and Payer Knowledge</h3><ul><li>Maintains up-to-date knowledge of CMS, JCAHO, FI, Medicare, Medicaid, and commercial payer requirements.</li><li>Participates in continuing education and compliance training related to medical terminology, anatomy, physiology, disease processes, and surgical procedures.</li><li>Maintains and updates payer reference materials, including authorization requirements and coverage changes.</li><li>Ensures compliance with HIPAA, Illinois Fair Patient Billing Act, Illinois Uninsured Patient Discount Act, and hospital policies.</li></ul><hr/><h3>Revenue Cycle & Financial Clearance</h3><ul><li>Verifies insurance benefits and communicates coverage, authorization requirements, and self-pay responsibilities to patients and families.</li><li>Identifies and resolves issues that may lead to claim denials, retrospective medical necessity reviews, or benefit reductions.</li><li>Contacts payers and patients to facilitate timely reimbursement and resolve billing issues.</li><li>Supports point-of-service collections by collecting co-pays, deposits, and patient financial responsibility using electronic payment systems.</li><li>Reviews rejected or unresolved accounts and works toward resolution through eligibility verification or financial assistance determination.</li></ul><hr/><h3>Systems, Documentation & Workflow Management</h3><ul><li>Maintains accurate documentation of authorization status, benefit verification, and payer communications in hospital billing systems (e.g., Cerner).</li><li>Independently tracks authorization requests and outcomes through completion.</li><li>Utilizes payer websites and internal tools to ensure accurate and timely submission of authorization requests.</li><li>Ensures all pre-certification documentation is completed prior to patient arrival to minimize delays and financial risk.</li></ul><hr/><h3>Interdepartmental Coordination & Communication</h3><ul><li>Coordinates with Patient Financial Services, Managed Care, Case Management, Scheduling, Clinical departments, and Social Services to ensure consistent documentation and workflow alignment.</li><li>Provides administrative and operational support to clinical and medical management teams, including concurrent review functions.</li><li>Communicates authorization issues or payer delays to appropriate stakeholders to ensure timely resolution.</li></ul><hr/><h3>Patient Financial Assistance & Education</h3><ul><li>Educates patients on insurance coverage, advance directives, Medicare Part D, and grievance processes.</li><li>Refers patients to Medicaid vendors or financial assistance programs when appropriate.</li><li>Applies knowledge of regulatory billing protections and uninsured patient discount programs.</li></ul><hr/><h3>Performance, Productivity & Operational Standards</h3><ul><li>Meets productivity standards (approximately 40–45 encounters processed daily).</li><li>Maintains accuracy, efficiency, quality, patient satisfaction, and attendance benchmarks.</li><li>Meets or exceeds point-of-service collection goals and revenue cycle performance metrics.</li><li>Participates in cross-training, mentoring, and onboarding of new staff.</li><li>Supports leadership with special projects, workflow improvements, and departmental initiatives.</li><li>Demonstrates flexibility to work additional hours, nights, weekends, or shift coverage as needed.</li></ul><hr/><h3>Professionalism & Compliance</h3><ul><li>Maintains superior patient relations using tact, professionalism, and sound judgment.</li><li>Adheres to all HIPAA, Joint Commission, CDC, and organizational compliance standards.</li><li>Completes required certifications and ongoing revenue cycle education.</li><li>Participates in mandatory meetings and contributes to continuous improvement initiatives.</li></ul>

Memorial Health

Insurance Pre-Auth Spec I

Administrative Skills

Analysis Skills

Anatomy

Benchmarking

Billing

Call Centers

Case Management

Centers for Disease Control and Prevention (CDC)

Centers for Medicare and Medicaid Services (CMS)

Cerner

Clinical Study Publications

Clinical Support

Clinical Training

Co-Payments

Coding Standards

Communication Skills

Community and Social Services

Concurrency

Continuous Improvement

Credit and Collections

Disease

Documentation

Emergency Services

Financial Management

Financial Risk

Financial Services

Government

HIPAA (Health Insurance Portability and Accountability Act)

Healthcare

Healthcare Providers

Hospital

Hospital Systems

Identify Issues

Industry/Trade Analysis

Insurance

Interpersonal Skills

Leadership

Maintain Compliance

Managed Care

Medicaid

Medical Billing

Medical Coding

Medical Office

Medical Terminology

Medical Treatment

Medicare

Mentoring

Microsoft Excel

Microsoft Office

Microsoft Outlook

Microsoft Word

Negotiation Skills

Nursing

Onboarding

Operational Support

Outpatient Care

Patient Admissions

Patient Care

Patient Care Authorizations

Patient Care Denials

Patient Education

People Management

Performance Metrics

Physiology

Problem Solving Skills

Regulations

Regulatory Compliance

Regulatory Requirements

Reimbursement

Service Delivery

Social Work

The Joint Commission (TJC)

Third-Party Payer

Time Management

Training/Teaching

Utilization Management

eLearning

[AW]-iCims

Previous experience in value-based care, home care, primary care, hospice, palliative care, or geriatrics strongly preferred, other complex patient health care experience also beneficial (preferred). Prior healthcare experience in areas of medical assistant, certified nursing assistant, EMT/paramedic, lab assistant, registered nurse, or similar health care related roles (preferred).

YEAR

Job Summary:
<p style="margin:0px"><strong>Join a Top-Rated Healthcare Company Making a Difference in Senior Care!</strong></p><p style="margin:0px"> </p><p style="margin:0px">WellBe Senior Medical was founded in 2019 to provide a more effective and personalized healthcare experience for patients living with chronic conditions. Our home-based medical visits nurture all aspects of a patient’s well-being so they can live better, feel healthier, and stay independent longer. With our mission at the forefront of everything we do, we aim to build our team with the most capable and compassionate individuals we can find. Named a Best Place to Work from Modern Healthcare, WellBe is a leading provider of in-home medical care and mental health services across the country!</p><p style="margin:0px"> </p>

Job Description:
<p style="margin-bottom:0in"><strong>What APP – Nurse Practitioners Love About WellBe:</strong></p><ul><li style="margin-bottom:0in"><strong>$20,000 sign on bonus.</strong></li><li style="margin-bottom:0in">Competitive salary and full benefits package. $120,000.00 to $140,000.00</li><li style="margin-bottom:0in">Meaningful, one-on-one care with your own patient panel.</li><li style="margin-bottom:0in">Mileage reimbursement</li></ul><p style="margin:0px"> </p><p style="margin:0px"><strong>WellBe’s Culture is Welcoming:</strong></p><ul><li>Be part of something important:</li><li><ul><li>Be part of pioneering a new way of healthcare that is revolutionizing the industry. </li><li>A patient-focused environment that ensures patients can live a fulfilling life whatever their health level is. Our focus is to give our patients more good days.</li></ul></li><li>Give yourself incredible opportunities:</li><li><ul><li>Work as part of a collaborative team with a strong team culture.</li><li>Training in the WellBe model and team-based care. Full in-person orientation, vision, mission, and values introduction, and instilling cultural ideals.</li><li>Empowerment and ownership for solving problems that arise and doing the right thing in each interaction.</li></ul></li></ul><p style="margin:0px"> </p><p style="margin:0px"><strong>Your APP – Nurse Practitioner Responsibilities:</strong></p><p style="margin:0px"> </p><ul><li>Will primarily support in-home, patient-facing visits to support patient care needs in the market.</li><li>Performs primary care in home services, initial patient screenings/physical examinations, creates appropriate assessment/plan and completes documentation in a timely manner.</li><li>Partners with other clinicians in the Care Community managing the health and wellbeing of patients living in their homes.</li><li>Responsible for engaging attributed patients into the WellBe program and supporting care needs and efforts to keep patients engaged.</li><li>Facilitates staff, patient, and family decision-making by providing educational resources.</li><li>Addresses any urgent care needs of the patients as needed, including transition of care visits.</li><li>Collaborates with community team to complete a full patient care assessment and plan.</li><li>Orders, interprets, and analyzes diagnostic tests and determine the need for follow-up. appointments and further treatment options per state supervisory agreement.</li><li>Prescribes and manage medications and treatments as appropriate, including but not limited to as psychopharmacological agents per state supervisory agreement.</li><li>Updates patient records and check records for accuracy at each patient appointment.</li><li>Delivers patient care and completes regular patient reviews with supervising physician per state supervisory agreement.</li><li>Focuses clinical care delivery to support necessary items for documentation/coding, HEDIS measures, engagement of patients, and managing medical expenses.</li><li>Utilizes all available resources to help care for patient needs and refers to internal/external resources as appropriate, such as WellBe behavioral health protocols.</li><li>Collaborate with the interdisciplinary team and participate in regularly scheduled team meetings.</li><li>Oher tasks needed to accomplish team’s objectives/goals.</li></ul>

Job Requirements:
<p style="margin:0px"><strong>APP – Nurse Practitioner Qualifications</strong></p><ul><li>Master’s Degree, Nursing with focus on Family Nurse Practitioner, Adult Nurse Practitioner, Geriatric Nurse Practitioner or Adult-Geriatric Nurse Practitioner from an accredited, Nurse Practitioner program (required)</li><li>Active, unencumbered Nurse Practitioner license in the state of job posting and must reside in state (required)</li><li>Current board certification in your field with either ANCC (American Nurses Credentialing Center) or AANP (American Association of Nurse Practitioners) (required)</li><li>BLS certified and an active NPI# as an NP (required)</li><li>CPR certification (required)</li><li>Active, unencumbered DEA licensure or eligibility to obtain (required)</li><li>Have a valid driver’s license, car insurance, have access to a car and willingness to drive to patient homes as site of care delivery</li><li>Requires proof of an active auto insurance policy (required)</li></ul><p style="margin:0px"> </p><p style="margin:0px"><strong>APP – Nurse Practitioner Skills We Value</strong></p><ul><li>3+ years Nurse Practitioner experience (preferred), will consider new grads</li><li>Prior healthcare experience in areas of medical assistant, certified nursing assistant, EMT/paramedic, lab assistant, registered nurse, or similar health care related roles (preferred)</li><li>Previous experience in value-based care, home care, primary care, hospice, palliative care, or geriatrics strongly preferred, other complex patient health care experience also beneficial (preferred)</li><li>Additional experience with telehealth care delivery (preferred)</li><li>Requires homes visits to patients in a variety of residential settings</li><li>Ability to conduct in- home setting visits and have previous experience on a telehealth platform</li><li>Demonstrated role proficiency with Microsoft Office; Excel, Word, G-suite, etc.</li><li>Proficient with office software, including Electronic Health Records, Scheduling Software and Ring Central applications</li></ul><p style="margin:0px"> </p><p style="margin:0px"><strong>Safety-Sensitive Statement</strong>:<br/>This position has been designated as safety-sensitive. As such, the employee must be able to perform job duties in a manner that ensures the safety of themselves, coworkers, patients, and the public. The role requires full cognitive and physical functioning at all times. Employees in safety-sensitive positions are subject to drug and alcohol testing, including for substances that may impair judgment or motor function, in accordance with applicable federal and state laws and company policy. Due to the safety-sensitive nature of this role and in alignment with federal law and workplace safety standards, the use of marijuana—including medical or recreational use—is prohibited. WellBe Senior Medical<br/>will comply with applicable state laws regarding medical marijuana and reasonable accommodations, where such laws do not conflict with safety requirements or federal regulations.</p><p style="margin:0px"><br/><strong>Drug Screening Requirement</strong>:<br/>As a condition of employment, WellBe Senior Medical requires all candidates to successfully complete a pre-employment drug screening. Ongoing employment may also be contingent upon compliance with the company’s Drug-Free Workplace Policy, which includes random, post-accident, and reasonable suspicion drug testing. The company reserves the right to test for substances that may impair an employee’s ability to safely and effectively perform their job duties.</p><p style="margin:0px"><br/><strong>Americans with Disabilities Act:</strong><br/>WellBe Senior Medical is committed to complying with the Americans with Disabilities Act (ADA) and applicable state and local laws. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the job. If you require an accommodation during the application or employment process, please contact Human Resources at </p><p>HRPeopleLine@wellbe.com</p><p/><p style="margin:0px"> </p><div><strong>*Please note:</strong> The salary range provided reflects the potential compensation for this role, but it does not guarantee an offer within that range. Final offers are based on factors like your experience, skills, and overall fit for the position.  </div><div> </div><p style="margin:0px"><em>This requisition is an evergreen position. It will remain open for ongoing recruitment and will serve as a talent pool for future hiring needs within the organization.</em></p><p style="margin:0px"> </p><p style="margin:0px"> </p><p style="margin:0px">                     </p><p style="margin:0px"><strong><u>Supervisory Responsibility</u></strong><strong>:</strong> This position will have supervisory responsibility.</p><p style="margin:0px"> </p><p style="margin:0px"><strong><u>Travel requirements</u></strong><strong>: </strong> Travel may be required up to 100% locally to deliver patient care.</p><p style="margin:0px"> </p><p style="margin:0px"><strong><u>Work Conditions:</u></strong> Ability to lift up to 30 lbs.  Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assisting with weights of more than 100lbs.  Ability to stand for extended periods.</p><p style="margin:0px">Ability to drive to patient locations (ie. home, hospital, SNF, etc).  Fine motor skills/Visual acuity.</p><p style="margin:0px"> </p><div><p style="margin:0px"><strong>The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, change or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodation so that a qualified employee(s) can perform the essential functions of this role</strong></p></div>

Wellbe Senior Medical

Nurse Practitioner - IL

Adult Nurse Practitioner (ANP)

American Nurses Credentialing Center (ANCC)

Auto Insurance

Basic Life Support (BLS)

Behavioral Health

CPR Certification

Calendar Management

Certified Medical Assistant

Certified Nursing Assistant (CNA)

Clinical Medicine

Community Health

Corporate Compliance

Corporate Policies

Documentation Plan

Driver's License

EMT-Paramedics

Emergency Nursing

Expense Management

Family Nurse Practitioner (FNP)

Federal Laws and Regulations

Geriatrics

Healthcare Effectiveness Data and Information Set (HEDIS)

Home Care

Hospice Care

Lift/Move 30 Pounds

Lift/Move 50 Pounds

Medical Assistance

Medical Records

Medications

Nurse Practitioner

Nursing Credentials

Palliative Care

Patient Assessment

Primary Care

Product/Service Launch

Psychiatry and Mental Health

Psychopharmacology

Registered Nurse (RN)

Safety/Work Safety

State Laws and Regulations

Team Building

Team Lead/Manager

Team Player

Telehealth

United States Drug Enforcement Agency (DEA)

Urgent Care

Willing to Travel

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Insurance Pre-Auth Spec I Memorial Health

Nurse Practitioner - IL Wellbe Senior Medical

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