Network Prior Auth & Referral Specialist

St. Luke's University Health Network•Allentown, PA

6d•Onsite

About The Position

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.

Requirements

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

Nice To Haves

Bilingual preferred.

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.