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Kalispell Regional Healthcare Prior-Authorization Specialist in Kalispell, Montana


The Prior-Authorization Specialist is responsible for obtaining prior authorizations for allprocedural orders by successfully completing the prior authorization process per department procedure and protocol.


  1. *Responsible for obtaining accurate prior authorizations for facility and professional charges related to scheduled patient appointments per department procedure and protocol. Performs timely and accurate submission of CPT, HCPCS codes and medical records to insurance carriers to expedite prior authorization requests.

  2. *Accurately secures patients’ demographics and medical information and ensures all procedures are in line with HIPPA compliance and regulations.

  3. *Reviews accuracy and completeness of information requested and ensures all supporting documents are present. Collaborates with stakeholders as appropriate.

  4. *Prioritizes incoming authorization requests according to department procedure and protocol. Confirms accuracy of CPT and ICD 10 diagnoses in the procedure order.

  5. *Maintains the WIRE to payer requirements needed to successfully obtain a prior authorization.

  6. *Contacts patient and/or clinic to advise if authorization request has not been obtained prior to date of service.

  7. *Researches and works with appropriate stakeholders in initiating retro authorization requests and resolving authorization denials as needed. . Prepares, submits, and tracks appeals as necessary. Accurately documents patient accounts of all actions taken.

  8. *Informs, educates, and communicates with leadership to include, but may not be limited to; billing or authorization concerns, backlogs, insurance issues, problematic accounts, documentation issues, etc.

  9. *Adapts to changing circumstances to meet the needs of patient flow.

  10. *Exhibits written and verbal professionalism at all times when interacting with others. Ensures all departmental transactions and interactions are completed with integrity, confidentiality, and professionalism.

  11. Other duties as assigned. This position description in no way states or implies that these are all the only duties required. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.

*Maintains regular and consistent attendance as scheduled by department leadership.

*Job duties denoted with an asterisk are classified as Essential Job Functions.


  1. Minimum of two (2) years’ experience in an acute care hospital, specialty clinic and/or medical billing office obtaining pre-certifications and/or prior-authorizations highly required.

  2. Possess knowledge and understanding of commercial and government insurance requirements, medical terminology, and rules and regulations governing the handling of private health information required.

  3. Possess a working knowledge and understanding of ICD-9 and CPT codes required.

  4. Possess insight and understanding into reimbursement and claims procedures and its direct impact on the revenue cycle required.

  5. Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed. Meditech experience preferred.

  6. Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.

  7. . Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently. .

  8. Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

Job Locations US-MT-Kalispell

Requisition ID 2021-10605

Category Accounting / Financial Services

Pay Period Status 80

Shift Days

Shift Start Hours 8:00 AM

Shift End Hours 5:00 PM


Position Type Full Time (Benefits Eligible)