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Prior Authorization Associate
PN Access and Authorizations
Full Time
Day Shift
M-F 8a-5p
Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer.
Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.
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-peers 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.
We are committed to offering quality, cost-effective benefits choices for our employees and their families:
- Day ONE medical, dental and life insurance benefits
- Health care and dependent care flexible spending accounts (FSAs)
- Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
- Employer paid life insurance – equal to 1x salary
- Employee may elect supplemental life insurance with low cost premiums up to 3x salary
- Adoption assistance
- LHI provides its full-time employees 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.
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