Prior Authorization Associate

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: One Year of Referral and/or Authorization Experience
Substitutable Education & Experience (Optional): 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.