Network Prior Authorization and Referral Specialist, Full Time

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

About The Position

Responsible for accurate and timely pre-registration and submission of prior authorizations for SLPG Primary Care and Specialty practices, as well as insurance referrals for Primary Care and Care Now departments. The role also handles peer-to-peer evaluations, verification and validation of financial information, and point-of-service cash collection for assigned services to help ensure proper reimbursement. The specialist reviews medical necessity for genetic testing and infusion services, monitors scheduled hospital diagnostic and surgical appointments for financial clearance, and processes authorizations for STAT imaging and other diagnostic orders. The position uses designated Epic work queues to document and bill authorization and referral workflows, notifies external providers about authorization requirements, communicates denials to practices, and reviews payer policies and contacts health plan utilization review departments for initial appeal mitigation.

Requirements

High school graduate or equivalent.
At least one year of experience in a hospital, physician's office, or similar medical facility department or office.
Knowledge of health insurance.
Strong customer service skills.
Ability to work independently.
Computer experience.

Nice To Haves

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

Responsibilities

Ensure accurate and timely financial clearance of scheduled patients by verifying financial information and obtaining precertifications and referrals for services.
Review medical necessity for genetic testing and infusion services in addition to obtaining prior authorization.
Monitor scheduled hospital diagnostic and surgical appointments to identify cases and obtain financial clearance.
Submit prior authorizations for STAT imaging orders for Primary Care and Specialty practices before the date of service.
Submit insurance referrals for Primary Care, Specialty, and SL Care Now orders.
Submit prior authorizations for diagnostic orders placed by Primary Care and Specialty service lines.
Use designated Epic work queues to follow authorization and referral workflows and ensure proper 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 initial appeal mitigation.
Perform peer-to-peer evaluations, verify and validate financial information, and collect point-of-service payments for assigned services.