Prior Authorization Associate

Lexington Health; Columbia (SC); On-site; USD 40,000 - 50,000; Full time

Benefits offered by this job

Day ONE medical, dental and life insurance benefits

Health care and dependent care flexible spending accounts (FSAs)

403(b) match plan day one

Employer paid life insurance

Tuition reimbursement

Student loan forgiveness

Job summary

Lexington Health is seeking a dedicated professional to authorize referrals prior to patient appointments. Utilizing Epic and Experian RTA systems, you will manage prior authorizations for imaging and specialty services, ensuring accurate clinical information submission.

Minimum qualifications include a High School Diploma and at least 6 months of relevant experience. The role offers comprehensive benefits, including medical, dental, and tuition reimbursement.

Qualifications

• Minimum 6 months of referral and/or authorization experience.

Responsibilities

• Authorize referrals prior to patient appointments.
• Utilize Epic Referral Work Queues and Experian RTA for prior authorizations.
• Communicate authorization updates to departments.

Skills

Strong Medical Terminology and Insurance Knowledge

Knowledge of ICD-10 and CPT Coding

Education

High School Diploma or Equivalent

Job description

Job Summary

Responsible for accurately authorizing referrals prior to patient appointments. Utilizes Epic Referral Work Queues, Experian Real Time Authorization (RTA), phone, payer websites and fax to complete prior authorizations for imaging and specialty services. Communicates authorization updates to appropriate departments. Verifies all pertinent clinical information is submitted in order for authorization to be processed accurately. Documents all information within the referral record and chart in Epic to include approvals, denials, peer-to-peer and pending authorizations.

Minimum Qualifications

• Minimum Education: High School Diploma or Equivalent
• Minimum Years of Experience: 6 months of referral and/or authorization experience
• Substitutable Education & Experience: None.
• Required Certifications/Licensure: None.
• Required Training: Strong Medical Terminology and Insurance Knowledge; Knowledge of ICD-10 and CPT Coding

Essential Functions

• Understands the referral process start to finish and acknowledges authorization as an important step in the overall process.
• Meets authorization volume and quality standards set monthly.
• Thoroughly reviews patient charts in Epic, submits the appropriate clinicals for authorization to the correct payer/third party vendor, obtains final determination from payer and enters information into EPIC.
• Utilizes Experian RTA system to obtain authorization and verifies authorization completion within system.
• Communicates all necessary authorization updates and status changes to the appropriate department(s).
• Communicates peer-to-peer requests to PN practices for providers/clinical staff to complete in order to obtain an authorization from payer.

Duties & Responsibilities

• Partners with LMC departments and insurance companies to provide quality care to LMC patients through the authorization process prior to patients' date of service.
• Escalates difficult issues, problems, questions and process improvement suggestions to management.
• Works with team to ensure timely process of authorizations. Participates in team problem solving activities, focuses on production and quality.
• Performs other duties as assigned.

Benefits

• Day ONE medical, dental and life insurance benefits
• Health care and dependent care flexible spending accounts (FSAs)
• 403(b) match plan day one; LHI matches dollar for dollar up to 6%.
• Employer paid life insurance – equal to 1x salary
• Supplemental life insurance up to 3x salary
• Adoption assistance
• Employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
• Tuition reimbursement
• Student loan forgiveness

Equal Opportunity Employer

It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination‑free environment, and to recruit, select, on‑board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.