Authorization Rep

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

6/25/2026

Entity:

Wisconsin

Job Code:

440031

Job Title:

Authorization Rep

FLSA Exemption Status:

Non-Exempt

Management Level:

Individual Contributor

JOB SUMMARY

The Authorization Representative supports patient access to procedures by obtaining prior authorization from payers for inpatient and outpatient services provided by UW Health.  The Authorization Representative role is key to proactively securing reimbursement, minimizing organizational write offs, educating patients on UW Health Payment Collection Policy, identifying efficiency opportunities related to the prior authorization workflows, documenting of activities on all applicable software platforms including the electronic health record, and providing an accurate clinical patient review.  The incumbent will assist in training prior authorization functions and serve as a resource to other departments with questions regarding prior authorizations. When an authorization cannot be obtained, the incumbent must be able to educate staff, providers, and/or patients on the options and complete the necessary steps to resolve the barriers to obtaining the prior authorization and/or to bring closure to the case.

The Authorization Representative must consistently demonstrate the use of critical thinking skills, skilled communication and troubleshooting techniques as well as have excellent customer service skills. This position will have the ability to anticipate and respond to a wide variety of issues/concerns, and the ability to execute tasks efficiently and effectively. The position requires the ability to independently plan, schedule and organize numerous tasks as this position directly impacts patient care, hospital, and physician reimbursement. A substantial portion of the normal duties of the incumbent requires proper judgment, sensitivity, and strict adherence to UW Health policy on confidentiality.

ESSENTIAL DUTIES

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Confirms the need for an authorization and takes the appropriate actions to ensure the authorization is obtained.

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Submits clinical information to third party payers to secure coverage for all high-end services provided, including, but not limited to, surgical cases, imaging, in clinic procedures, diagnostic testing, rehab, orthotics and prosthetics.

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Tracks status of prior authorization requests from initial submission through final insurance determination.

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Verifies the basic patient/service information is available - the minimum data set for securing a prior authorization. If not present, initiates appropriate activity to obtain the required data set, such as missing coverage information, procedure, and diagnosis codes.

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Ensures coverage eligibility, deems if care is a covered service, determines if there are site of service or out of network restrictions, etc.

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Prioritizes the urgency of the authorization by anticipating the approximate time it may take to obtain the authorization from the insurance company, the complexity of the procedure and the scheduled date of service; follows up with insurance company to accelerate responses and expedite urgent/emergent authorizations.

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Evaluates or assists with the status of cases when the insurance company has denied payment to determine next steps; this may include building a case for appeal.

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Interacts with medical and professional staff to obtain appropriate clinical documentation for review; this may include referring stakeholders to a member of the clinical authorization team. Takes the appropriate actions when the authorization will not be provided in a timely manner; including escalation to leadership, the patients care team or the clinical authorization team.

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Determines if medical policy exists, and if possible, will ensure that a case meets payer requirements. When unable to discern if a case meets the medical policy, will escalate the case appropriately to the clinical authorization specialists or the patients care team.

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Understands the critical delineations of patient status (outpatient, inpatient and observation) based on payor regulations and participates in the appropriate decision making with the clinical team members such as care management, coding, or billing.

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Advises and coordinates with providers regarding problematic (i.e., high risk) admissions or any episode of service requiring additional attention.

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Communicates with patients when an authorization is not able to be secured, provides options, and de-escalates concerns when they arise relating to denials and/or cancellation of cases/procedures.

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Educates patients on payment expectation, collects pre-payments and verbal financial responsibility agreements, when necessary, for a patient to proceed with their care.

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Supports the single case agreement process by using critical thinking skills, and an ability to discern when these are needed, and then escalating appropriately, including ensuring follow up is completed.

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Supports co-workers and engages in positive interactions.

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Communicates professionally and timely with internal and external customers.

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Provides helpful assistance in anticipating and responding to the needs of our customers.

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Collaborates with customers in planning and decision making to result in optimal solutions.

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Ability to stay calm under pressure and deal effectively with difficult situations.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

No minimum education

Required

High school diploma or equivalent.

Preferred

Associate's Degree

in Business, Finance, Health Information Management, or a related field

Preferred

1 year

of experience in healthcare, business, finance, or insurance related field

Required

1 year

of experience in Healthcare Revenue Cycle that includes prior authorization

Preferred

Knowledge of CPT and ICD coding highly desired

Preferred

Knowledge of Medicare and third-party payer regulations and guidelines highly desired

Preferred

Knowledge of Epic Software, use of Rfax, and Calabrio Call System

Preferred

Experience with payment collections

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

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Maintains current knowledge of medical modalities as well as new protocols established for patient populations.

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Solid understanding and knowledge of payer contractual requirements, registration workflows, and prior authorization requirements to ensure staff follow established procedures to maximize reimbursement and minimize write offs.

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Excellent written and oral communication skills.

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Maintains effective and cooperative working relationships with co-workers, leaders, clinical staff, and the public.

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Must be detail oriented and accurate.

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Ability to multi-task and prioritize tasks.

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Displays an aptitude and willingness to learn new responsibilities.

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Willingly accepts feedback.

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Flexible and innovative.

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Ability to problem-solve and work independently.

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Displays a professional appearance.

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Dependable and reliable in achieving goals.

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Experience with use of personal computers in a home workspace.

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Familiarity with medical terminology and abbreviations.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

☒

Sedentary: Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

☐

Light: Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If someone can do light work, we determine that they can also do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

☐

Medium: Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds. If someone can do medium work, we determine that they can also do sedentary and light work.

20-50#

10-25#

Negligible-10#

☐

Heavy: Heavy work involves lifting no more than 100 pounds at a time with frequent lifting or carrying of objects weighing up to 50 pounds. If someone can do heavy work, we determine that they can also do medium, light, and sedentary work.

50-100#

25-50#

10-20#

☐

Very Heavy: Very heavy work involves lifting objects weighing more than 100 pounds at a time with frequent lifting or carrying of objects weighing 50 pounds or more. If someone can do very heavy work, we determine that they can also do heavy, medium, light, and sedentary work.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.