Network Prior Authorization and Referral Specialist, Full Time

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

About The Position

The Network Prior Authorization and Referral Specialist is responsible for accurate, timely pre-registration and financial clearance for scheduled patients. The role submits prior authorizations for SLPG Primary Care and Specialty practices, insurance referrals for Primary Care and Care Now departments, and peer-to-peer evaluations. It verifies and validates financial information and collects point-of-service payments for assigned services to support proper reimbursement. The specialist reviews medical necessity for genetic testing and infusion services, monitors scheduled hospital diagnostic and surgical appointments to ensure cases are identified and financially cleared, and uses designated Epic work queues to document and process prior authorization and referral workflows. The role also communicates authorization requirements and denials to providers and practices, provides peer-to-peer information for scheduling, and reviews payer medical policies and contacts health plan utilization review departments for initial appeal mitigation.

Requirements

High school diploma or equivalent.
At least one year of experience in the stated healthcare areas is required.
Strong customer service skills and knowledge of health insurance are required.
Ability to work independently.
Computer experience.
Three years of healthcare experience in a hospital, physician's office, or similar medical facility is preferred.
Bilingual ability is preferred.

Nice To Haves

Three years of healthcare experience in a department or office within a hospital, physician's office, or similar medical facility.
Bilingual ability.

Responsibilities

Provide accurate, timely verification of financial information and precertification or referrals for scheduled services to ensure proper reimbursement.
Review medical necessity for genetic testing and infusion services, in addition to obtaining prior authorization.
Monitor scheduled hospital diagnostic and surgical appointments to ensure each case is identified and financial clearance is obtained.
Submit prior authorizations for STAT imaging orders for Primary Care and Specialty practices before the date of service.
Submit insurance referrals for PG Specialty and Primary Care orders and SL Care Now departments.
Submit prior authorizations for diagnostic orders placed by PG Primary Care and Specialty service lines.
Use designated Epic work queues for prior authorization and insurance referral workflows, following processes for documentation and billing.
Notify external providers of prior authorization requirements for scheduled services.
Notify practices of denied authorizations through in-basket messages and provide peer-to-peer information for scheduling.
Review payer medical policies and contact health plan utilization review departments for an initial attempt at appeal mitigation.
Verify and validate financial information and collect point-of-service cash for assigned services.