Prior Authorization Specialist

Lifepoint Health • Hancock, MI

18h

About The Position

A Prior Authorization Specialist who excels in this role contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients. This role involves following up with physician offices, financial counselors, patients, and third-party payers to complete the pre-certification process. The specialist collaborates with the Supervisor, internal departments, and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations. They ensure information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems. Additionally, the role includes educating patients, staff, and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance-related changes or trends. The specialist ensures all services have prior authorizations and updates patients on their preauthorization status, coordinating peer-to-peer review if required by insurance. They notify patient accounts staff/patients of insurance coverage lapses and self-pay patient status. The role may involve coordinating the scheduling of patient appointments, diagnostic and/or specialty appointments, tests, and/or procedures. The specialist maintains files for referral and insurance information and enters referrals into the system. They maintain knowledge of and reference materials for Medicare, Medicaid, and third-party payer requirements, guidelines, and policies, insurance plans requiring pre-authorization, and a list of current accepted insurance plans. The specialist serves as an expert for peers across the patient access continuum and meets daily productivity and quality standards associated with job requirements.

Requirements

• High School Diploma or Equivalent Required
• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.

Responsibilities

• Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients.
• Follows up with physician offices, financial counselors, patients, and third-party payers to complete the pre-certification process.
• Collaborates with Supervisor, internal departments and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.
• Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
• Educates patients, staff and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.
• Ensures all services have prior authorizations and updates patients on their preauthorization status. Coordinates peer to peer review if required by insurance.
• Notifies patient accounts staff/patients of insurance coverage lapses, and self-pay patient status.
• May notify ordering providers if authorization/certification is denied.
• May coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.
• Maintains files for referral and insurance information and enters referrals into the system.
• Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
• Serves as an expert for peers across the patient access continuum.
• Meets daily productivity and quality standards associated with job requirements.

Benefits

• Multiple levels of medical, dental and vision coverage for full-time and part-time employees.
• Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Ongoing learning and career advancement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED