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.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. Dedicated to advancing medical education, St. Luke’s is the preeminent teaching hospital in central-eastern Pennsylvania. In partnership with Temple University, the Network established the Lehigh Valley’s first and only four-year medical school campus. It also operates the nation’s longest continuously operating School of Nursing, established in 1884, and over 50 fully accredited graduate medical educational programs with more than 500 residents and fellows. In 2022, St. Luke’s, a member of the Children’s Hospital Association, opened the Lehigh Valley’s first and only free-standing facility dedicated entirely to kids. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY.
