FT or PT Hybrid Pain Management Pre-Auth Specialist

Role Overview

No Nights, Weekends, Holidays

We are seeking a dedicated Medical Billing Specialist to serve in a dual-function role at our WI facility. You will serve as the on-site point of contact for our Medicare 855B site inspection process and support our Pain Management Pre-Authorization Team.

This position is currently 5 days per week, on-site at 444 Reid Street, De Pere, WI 54115. As our clinical program scales and staffing grows, a hybrid schedule (rotating in-office and remote days) will become available. That transition will be communicated in advance with clear expectations.

Physical presence during the 10:00 AM to 2:00 PM - Monday through Friday (FT or Multiple PT to cover). Our facility is subject to unannounced CMS / MAC site inspections as part of a pending 855B application. A missed inspection results in automatic application denial. Punctuality and consistency are non-negotiable in this role.

On-Site Responsibilities

Medicare Site Inspection Compliance

• Serve as the sole dedicated physical presence at the facility during all posted operating hours.
• Act as the immediate, professional point of contact when a MAC field inspector arrives unannounced.
• Escort inspectors through the facility and respond to operational questions factually and without elaboration.
• Confirm each morning that the facility is open, utilities are operational, and equipment is functioning before 10:00 AM.
• Verify that external business signage is visible and in compliance.
• Maintain strict physical HIPAA compliance, including locked medical records storage and secured server areas.
• Maintain the Readiness Binder at the front desk at all times, containing:
• Active state facility licenses
• IRS CP-575 forms
• Current building lease
• Copy of the submitted 855B application

Pain ManagementPre-Authorization

We partners directly with pain management and orthopedic clinics to help optimize operations and improve financial performance. Prior authorizations are a critical component of that success.

We are seeking a Prior Authorization Specialist (Contract) to support high-volume authorizations for both procedures and prescription medications. This role focuses on provider/clinic-side workflows and requires someone who understands payer requirements, documentation standards, and how to proactively prevent downstream denials.

The ideal candidate is detail-oriented, experienced in complex authorizations, and comfortable working independently in a fast-paced environment.

What You’ll Be Doing

You will help ensure providers receive timely authorization approvals by managing the full lifecycle of prior authorization workflows.

Procedural Authorizations

• Submit and manage prior authorizations for pain management and orthopedic procedures, including:
• Epidural steroid injections
• Facet injections
• Radiofrequency ablation (RFA)
• SI joint injections
• Advanced imaging (MRI, CT)
• Orthopedic surgical procedures

Prescription Drug Authorizations

• Manage prior authorizations and reauthorizations for medications commonly used in pain management
• Navigate pharmacy benefit portals and step-therapy requirements
• Submit formulary exception and medical necessity documentation when required

Authorization Management

• Navigate multiple payer portals efficiently
• Verify insurance eligibility and benefits prior to submission
• Review provider documentation to confirm medical necessity and procedural alignment
• Follow up on pending or denied authorizations
• Identify documentation gaps before submission to reduce preventable denials
• Maintain clear documentation within EHR and tracking systems
• Support billing and reconciliation activities as needed, including resolving authorization-related billing issues

This role requires strong workflow discipline, attention to detail, and the ability to manage a high volume of requests accurately.

Required Qualifications

• 3 years of prior authorization experience in Pain Management or Orthopedics
• Demonstrated experience with:
• Interventional pain and/or orthopedic surgical authorizations
• Prescription drug prior authorizations (medical and pharmacy benefit)
• Experience working on the clinic/provider side (not hospital/facility billing)
• Ability to independently manage high daily authorization volume
• Hands-on experience with payer portals (e.g., Availity, UHC, Carelon/AIM, eviCore, Cohere, CoverMyMeds, etc.)
• Strong working knowledge of CPT codes and procedural terminology
• Experience reviewing documentation for medical necessity
• Exceptional attention to detail and follow-through

Strongly Preferred

• Experience with Medicaid plans
• CPC-A or other coding certification
• Familiarity with NCCI edits, bundling rules, and step therapy protocols
• Experience identifying recurring denial patterns and process gaps

What Success Looks Like

• Strong first-pass approval rates
• Minimal preventable authorization-related denials
• Consistent, timely submissions
• Clear documentation and communication
• Independent execution with limited supervision

Pay: $20.00 - $22.00 per hour

Experience:

• Pain Management Auth: 2 years (Required)

Work Location: Hybrid remote in De Pere, WI 54115

Salary : $20 - $22