Practice Prior Authorization and Referral Specialist (Rheumatology and Endocrinology)

St. Luke's University Health Network; Easton (Northampton County); Vor Ort; USD 40.000 - 56.000; Vollzeit

Zusammenfassung

St. Luke’s University Health Network is seeking an experienced Practice Prior Authorization and Referral Specialist to coordinate prior-authorizations and referrals for specialty care, medications, and diagnostic procedures.

The role requires accurate insurance verification, scheduling, and timely communication with patients and providers. Responsibilities include obtaining pre-authorizations, documenting approvals in the EHR, and following up on denials.

Qualifikationen

• High school diploma or equivalent required.
• Prior authorization experience preferred.

Aufgaben

• Coordinate prior-authorizations and referrals for specialty care, medications, and diagnostics.
• Verify patient demographics and insurance information for accuracy.
• Obtain prior authorization from insurers before services.
• Document approvals in the EHR to ensure proper reimbursement.
• Collaborate with scheduling and pre-encounters teams.
• Respond to inquiries from patients, insurers, pharmacies, and departments.
• Review denials and notify treating providers of outcomes.

Kenntnisse

Prior authorization

Insurance verification

Communication

Data entry

Scheduling

Ausbildung

High school diploma or equivalent

Tools

EHR software

ICD-10 coding

CPT coding

Jobbeschreibung

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.

The Practice Prior Authorization and Referral Specialist is responsible for the coordination of prior-authorizations and referral process for patients being referred for specialty care, medications, and diagnostic procedures. Performs insurance verification, obtaining pre-authorizations, scheduling, and referrals. The specialist will secure the necessary prior authorization, then notify the patient aiding in the coordination of patient care.

JOB DUTIES AND RESPONSIBILITIES:

• Receive request for patient requiring specialty care through the electronic health record (EHR), direct order by provider communication, phone, and/or fax.
• Ensure patient demographic as well as insurance information are most accurate.
• Reviews patient insurance information and eligibility / verification to obtain prior authorization for specialty care and/or services.
• Obtain prior authorization from insurance companies prior to services being ordered and/or rendered.
• Documents in EHR prior authorization approval to ensure proper reimbursement.
• Works in collaboration with other supporting services / entities, central scheduling, and pre-encounters department.
• Responds to written as well as telephone inquires from patients, insurances, pharmacies, other outpatient/inpatient departments, and facilities regarding planned specialty care and/or services.
• Review and follow up on authorization and/or claim denials.
• Notify ordering provider of a prior authorization denials and if peer to peer need to be scheduled.
• Other duties as assigned.

PHYSICAL AND SENSORY REQUIREMENTS:

Sitting for up to 8 hours per day, 3 hours at a time.Consistent use of hands and fingers for typing, telephone, data entry, etc.Occasional twisting and turning.Uses upper extremities to life and carry up to 15 pounds.Stoops, bends, and reaches above shoulder level to retrieve needed materials. Hearing as it relates to normal conversation. Seeing as it relates to general vision.

EDUCATION:

High school diploma or equivalent required. Prior authorization experience preferred.

TRAINING AND EXPERIENCE:

One to two years of experience in medical billing, a medical office or insurances preferred. Working knowledge of medical office procedures as well as detailed understanding of ICD 10 and CPT codes. Knowledge of regulatory standards and compliance requirements.

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