Network Prior Authorization and Referral Specialist, Full Time

sluhn; Allentown (Lehigh County); On-site; USD 28,000 - 36,000; Full time

Job summary

St. Luke's is seeking a detail‑oriented pre-registration and authorization specialist to ensure accurate financial clearance for scheduled patients.

You will verify patient information, submit prior authorizations, and coordinate insurance referrals for Primary Care and SL Care Now departments. Responsibilities include reviewing medical necessity, monitoring appointments, and using Epic Work Queues to maintain compliant documentation and timely reimbursements.

Qualifications

• High school graduate or equivalent.
• Three years healthcare experience in a department or office with a hospital, physician's office, or similar medical facility preferred.
• It is required to have at least one year in areas stated above.
• Strong customer service skills with knowledge of health insurances required.
• Must have the ability to work independently.
• Computer experience required.
• Bilingual preferred.

Responsibilities

• Responsible for the financial clearance of all scheduled patients by providing accurate and timely verification of all financial information and pre-certification/referral for all services to ensure proper reimbursement.
• Responsible for reviewing medical necessity of genetic testing/infusion services in addition to prior authorization to ensure revenue for services.
• Monitors all hospital scheduled diagnostic and surgical appointments to ensure that all cases are identified, and financial clearance is obtained.
• Submit prior authorizations for all STAT imaging orders for PCP and Specialty prior to date of service.
• Submit for insurance referrals for all PG Specialty and PCP orders and SL Care Now Departments.
• Submit prior authorizations for diagnostic orders placed by PG PCP and Specialty service lines.
• Utilizes Epic Work Queues designed for Prior Authorization and Insurance Referral workflows to ensure correct process is followed for proper documentation and billing in Epic.
• Notifies all external providers of prior authorization requirements for scheduled services.
• Notifies practices of all denied authorizations via in-basket message and provide peer to peer info for scheduling.
• Review payer medical policies and contact the health plan's UR department for first attempt appeal mitigation.

Skills

Customer service

Billing/insurance knowledge

Independent work

Proficient computer skills

Bilingual preferred

Education

High school graduate or equivalent

Tools

Epic

Job description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

Responsible for accurate and timely pre-registration, submission of prior authorizations for SLPG Primary Care and Specialty practices, submission of insurance referrals for all Primary Care and Care Now departments, peer to peer evaluations, verification and validation of all financial information, and Point of Service cash collection for all services assigned to ensure proper reimbursement.

JOB DUTIES AND RESPONSIBILITIES:

• R e sponsible for the finan cial c le a r a n c e of a ll s c h e duled p a ti e nts b y p ro v i d ing a c c u ra te a nd timely v e ri f ic a tion of a ll finan c i a l info r mation a nd p rec e rtifi ca tion/r e fer r a l f o r a ll s e rvi c e s to e nsure p r op e r r e imburs e ment.
• Responsible for reviewing medical necessity of genetic testing/infusion services in addition to prior authorization to ensure revenue for services.
• Monitors a ll hospital sch e duled diagnostic and surgical appointments to ensure that a ll ca s e s a re i d e ntified, a nd fin a n c ial c l ea r a n c e is obtain e d.
• Submit prior authorizations for all STAT imaging orders for PCP and Specialty prior to date of service.
• Submit for insurance referrals for all PG Specialty and PCP orders and SL Care Now Departments.
• Submit prior authorizations for diagnostic orders placed by PG PCP and Specialty service lines.
• Utilizes specific Epic Work Queues designed for Prior Authorization and Insurance Referral workflows to ensure correct process is followed for proper documentation and billing in Epic.
• Notifies all external providers of prior authorization requirements for scheduled services.
• Notifies practices of all denied authorizations via in-basket message and provide peer to peer info for scheduling.
• Review payer medical policies and contact the health plan's UR department for first attempt appeal mitigation.

PHYSICAL AND SENSORY REQUIREMENTS:

• Sitting up to e i g h t (8) hours p e r d a y , three (3) h ours a t a time. Consiste n t use of h a nds a nd fin g e rs for ty pi n g , tel e pho n e s, d a ta e nt r y , e tc. O c c a sional t w isting a nd turni n g . U s e s upp e r e x tr e miti e s to lift a nd ca r r y up to 15 pounds. Stoops, b e nds a nd r e ac h e s a bove should e r le v e l to r e trieve files. He a ri n g a s it r e lat e s to no r mal c on v e r s a tion. S ee ing a s it re lat e s to g e n e r a l vision.

EDUCATION:

Hi g h sc h ool g r a du a te o r e quival e nt.

TRAINING AND EXPERIENCE:

• Three years healthcare experience in a department or office with a hospital, p h y sici a n 's o f fi c e , or simil a r medi ca l f a c ili t y preferred. It is required to have at least one year in areas stated above.
• Strong c ustom e r s e rvi c e skills with kn o wl e d g e of h ea lth insur a n ce s required. M u st h a ve a bili t y to w o rk i n d e p e nd e nt l y . Comput e r e x p e ri e n c e r e qu i r e d. B ilin g u a l p refer r e d.

St. Luke's University Health Network is an Equal Opportunity Employer.