Physical Therapy at St. Luke's · 11 hours ago
Network Prior Auth & Referral Specialist
Allentown, PA
Part-time
Onsite
Entry, Mid Level
1+ years expSt. Luke's is dedicated to providing excellent care and improving access to healthcare in its communities. The Network Prior Auth & Referral Specialist is responsible for managing prior authorizations and referrals, ensuring financial clearance for patients, and facilitating communication with healthcare providers and insurance payers.
Health CareHospitalRehabilitation
Responsibilities
Responsible for the financial clearance of all scheduled patients by providing accurate and timely verification of all financial information and precertification/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 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
Providing information to patients regarding the prior authorization process, including any necessary steps or documentation required from their end
Communicating with healthcare providers to gather additional information, clarify documentation or address any concerns related to the prior authorization process
Contacts Insurance Payers to provide Notice of Admission on behalf of PG provider to secure reimbursement for Observation and Inpatient Services
Refers all self- pay patients to the Patient Advocacy Department
Identify patients scheduled with Out of Network Health Plans and refer patient to central scheduling to be rescheduled to in network SL facility or refer to Patient Advocacy Department to review alternative insurance plans in network with St. Luke’s
Updates and/or communicates correct patient information to appropriate staff, hospital departments, and computer systems
Review all patients with imaging and surgical order changes that require same day authorization updates
Responsible for investigating and reviewing all claim denials related to missing or invalid prior authorizations in addition to medical necessity denials for certain departments
Required education and working knowledge of Experian Prior Authorization module to assist in the obtaining of insurance authorizations
Responsible for writing appeal letters or retrospective medical review requests. Prompt resolution of imaging and surgical cases requiring authorization updates to cpt codes or implantable devices
Works with reimbursement Coordinators regarding updates and deleted codes for proper reimbursement for Departments
Works with Manager regarding reimbursements issues and or pre-cert issues with accounts in their area as upon request
Stays abreast of third-party medical policies and authorization requirement changes
Maintains relationships and supports SLPG practices and communicates discrepancies in obtained authorizations
Follow up on appointments with approved authorizations for cpt codes but require site of care coordination. Contact patient and refer them to the health plan to complete site of care interview needed prior to date of service
Performs other related duties as assigned
Qualification
Required
High school graduate or equivalent
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 ability to work independently
Computer experience required
Preferred
Three years healthcare experience in an outpatient department or business office with a hospital, physician's office, or similar medical facility preferred
Bilingual preferred
Company
Physical Therapy at St. Luke's
Physical Therapy at St. Luke's is a patient-oriented rehabilitation practice that emphasizes education, healing, and exceeds expectations.
201-500 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase