Prior Authorization Specialist

Lifepoint Health • Somerset, NJ

10d

About The Position

The Prior Authorization Specialist works with departments and insurance companies to obtain the necessary pre-certifications and authorizations for services ordered/scheduled. Once received these are recorded in Paragon to ensure appropriate billing. The Prior Authorization Specialist maintains a high level of understanding of insurance companies and billing authorization requirements.

Requirements

• Highschool diploma or equivalent
• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

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.
• Performs other job-related responsibilities as requested.

Benefits

• Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
• Competitive Paid Time Off / Extended Illness Bank package for full-time employees
• Employee Assistance Program – mental, physical, and financial wellness assistance
• Tuition Reimbursement/Assistance for qualified applicants
• Professional Development and Growth Opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees