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Network Prior Authorization and Referral Specialist

1 month ago

Allentown, United States St. Luke's University Health Network Full time


St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

Responsible for accurate and timely pre-registration, submission of prior authorizations for SLPG Primary Care and Specialty practices, submission of insurance referrals for all Primary Care and Care Now departments, peer to peer evaluations, verification and validation of all financial information, and Point of Service cash collection for all services assigned to ensure proper reimbursement.

The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

JOB DUTIES AND RESPONSIBILITIES:

  • Responsible for the financial clearance of all scheduled patients by providing accurate and timely verification of all financial information and precertification/referral for all services to ensure proper reimbursement.
  • Responsible for reviewing medical necessity of genetic testing/infusion services in addition to prior authorization to ensure revenue for services.
  • Monitors all hospital scheduled diagnostic and surgical appointments to ensure that all cases are identified, and financial clearance is obtained.
  • Submit prior authorizations for all STAT imaging orders for PCP and Specialty prior to date of service.
  • Submit for insurance referrals for all PG Specialty and PCP orders and SL Care Now Departments.
  • Submit prior authorizations for diagnostic orders placed by PG PCP and Specialty service lines.
  • Utilizes specific Epic Work Queues designed for Prior Authorization and Insurance Referral workflows to ensure correct process is followed for proper documentation and billing in Epic.
  • Notifies all external providers of prior authorization requirements for scheduled services.
  • Notifies practices of all denied authorizations via in-basket message and provide peer to peer info for scheduling.
  • Review payer medical policies and contact the health plan’s UR department for first attempt appeal mitigation.
  • Providing information to patients regarding the prior authorization process, including any necessary steps or documentation required from their end.
  • Communicating with healthcare providers to gather additional information, clarify documentation or address any concerns related to the prior authorization process.
  • Contacts Insurance Payers to provide Notice of Admission on behalf of PG provider to secure reimbursement for Observation and Inpatient Services.
  • Refers all self- pay patients to the Patient Advocacy Department.
  • Identify patients scheduled with Out of Network Health Plans and refer patient to central scheduling to be rescheduled to in network SL facility or refer to Patient Advocacy Department to review alternative insurance plans in network with St. Luke’s
  • Updates and/or communicates correct patient information to appropriate staff, hospital departments, and computer systems.
  • Review all patients with imaging and surgical order changes that require same day authorization updates.
  • Responsible for investigating and reviewing all claim denials related to missing or invalid prior authorizations in addition to medical necessity denials for certain departments.
  • Required education and working knowledge of Experian Prior Authorization module to assist in the obtaining of insurance authorizations.
  • Responsible for writing appeal letters or retrospective medical review requests. Prompt resolution of imaging and surgical cases requiring authorization updates to cpt codes or implantable devices.
  • Works with reimbursement   Coordinators   regarding   updates   and   deleted codes   for   proper reimbursement for Departments.
  • Works with Manager regarding reimbursements issues and or pre-cert issues with accounts in their area as upon request.
  • Stays abreast of third-party medical policies and authorization requirement changes.
  • Maintains relationships and supports SLPG practices and communicates discrepancies in obtained authorizations.
  • Follow up on appointments with approved authorizations for cpt codes but require site of care coordination. Contact patient and refer them to the health plan to complete site of care interview needed prior to date of service.
  • Performs other related duties as assigned.

PHYSICAL AND SENSORY REQUIREMENTS:

Sitting up to eight (8) hours per day, three (3) hours at a time. Consistent use of hands and fingers for typing, telephones, data entry, etc. Occasional twisting and turning. Uses upper extremities to lift and carry up to 15 pounds. Stoops, bends and reaches above shoulder level to retrieve files. Hearing as it relates to normal conversation. Seeing as it relates to general vision.

EDUCATION:

High school graduate or equivalent.

TRAINING AND EXPERIENCE:

Three years healthcare  experience  in  an  outpatient  department  or  business  office  with  a  hospital, physician’s office, or similar medical facility preferred. It is required to have at least one year in areas stated above.  Strong customer service skills with knowledge of health insurances required. Must have ability to work independently. Computer experience required. Bilingual preferred.

Please complete your application using your full legal name and current home address.  Be sure to include employment history for the past seven (7) years, including your present employer.  Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable.  It is highly recommended that you create a profile at the conclusion of submitting your first application.  Thank you for your interest in St. Luke's



St. Luke's University Health Network is an Equal Opportunity Employer.