Authorization Specialist

1004 Lehigh Valley Hospital; Pennsylvania; Hybrid; USD 45,000 - 65,000; Full time

Job summary

Lehigh Valley Health Network is seeking a remote Precertification Specialist to obtain authorizations for procedures, testing, medications, and referrals. You will determine authorization protocols per health plans and perform billing duties to ensure timely payments from insurers and patients.

The role requires collaboration with physicians, staff, and insurance companies, verifying information, and ensuring authorizations align with policies.

Qualifications

• High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs.
• 1 year in a healthcare setting with insurance verification/authorizations.
• Familiarity with billing procedures and payer reimbursement.
• Knowledge of patient rights and HIPAA regulations.
• Proficient in utilization management processes, standards, and managed care.

Responsibilities

• Collaborates with physicians and staff to determine the appropriate authorization based on medical necessity and the treatment plan.
• Performs a medical necessity check to determine if procedure and diagnosis support medical necessity.
• Ensures authorizations are obtained in accordance to network policy and communicates issues to ordering office, patient, and manager.
• Communicates with insurance companies to obtain verification, benefits and precertification for approval.
• Verifies additional clinical information and insurance authorizations/referrals.
• Reviews and monitors schedules to ensure proper authorization prior to patient visits.
• Maintains compliance with benchmark data regarding accounts registered versus scheduled procedures.
• Determines estimated patient financial responsibility using verification information and payer contracts.

Skills

Insurance verification

HIPAA knowledge

Billing procedures

Managed care

Education

High School Diploma

Associate degree preferred

Job description

Job Summary

Obtains benefits and authorizations for surgical procedures, diagnostic testing, medications, outgoing referrals, and other services as part of daily operations. Determines the authorization protocols for each health plan and performs billing duties to ensure proper and timely payment is received from insurance carriers and patients.

Job Duties

• Collaborates with physicians and provider office staff in ascertaining the appropriate authorization based on medical necessity and the treatment plan provided.


• Performs a medical necessity check to determine if procedure and diagnosis support medical necessity.


• Ensures authorizations are obtained in accordance to network policy (any authorization not falling into policy guidelines is communicated to ordering office, patient, and manager).


• Communicates direct/indirect with insurance companies to obtain insurance verification, benefits and precertification for approval.


• Verifies additional clinical information and insurance authorizations/referrals.


• Reviews and monitors WQs/schedules to ensure that proper and accurate authorization has been received prior to patient’s visit.


• Maintains compliance with benchmark data regarding accounts registered versus scheduled procedures.


• Determines estimated patient financial responsibility using insurance verification information and payer contracts and/or self-pay guidelines.

Minimum Qualifications

• High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs.


• 1 year in a healthcare setting with insurance verification/authorizations.


• Familiarity with billing procedures and payer reimbursement.


• Knowledge of patient rights and laws relative to those rights, such as HIPAA.


• Proficient in utilization management processes, standards, and managed care.


• Proficient in standard medical practices and insurance benefit structures.

Preferred Qualifications

• Associate’s Degree


• Physical Demands Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Work Shift

Day Shift

Address

1200 S Cedar Crest Blvd

Location

REMOTE IN PENNSYLVANIA

Position Type

Remote

Work Schedule

Monday-Friday 8:00a-4:30p

Department

1004-13036 COH-Precertification Dept Lehigh Valley Health Network (LVHN)

Disclaimer

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Equal Opportunity

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

Lehigh Valley Health Network does not accept unsolicited agency resumes. Agencies should not forward resumes to our job aliases, our employees or any other organization location. Lehigh Valley Health Network is not responsible for any agency fees related to unsolicited resumes.

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Company Culture

Lehigh Valley Health Network (LVHN) is the region’s largest employer and health care provider of choice. Our nearly 20,000 health care professionals take pride in what they do and are driven by our mission to heal, comfort and care for the people of our community. LVHN is honored to be certified as a Great Place to Work®. LVHN’s culture of trust – and the positive things colleagues said about working at LVHN when surveyed by Great Place to Work and Fortune – align perfectly with what makes a great workplace. This designation tells you that LVHN is a great place to work from hire to retire. If you are someone who aligns with LVHN’s core values – Compassion, Integrity, Collaboration and Excellence – you will have a rewarding and successful career here.