Authorization Specialist
Lehigh Valley Health Network
Summary
Obtains benefits and authorizations for surgical procedures, diagnostic testing, medications, outgoing referrals, and other services as part of daily operations. Determines the authorization protocols for each health plan and performs billing duties to ensure proper and timely payment is received from insurance carriers and patients.
Job description
Summary
Obtains benefits and authorizations for surgical procedures, diagnostic testing, medications, outgoing referrals, and other services as part of daily operations. Determines the authorization protocols for each health plan and performs billing duties to ensure proper and timely payment is received from insurance carriers and patients.
Job Duties
- Collaborates with physicians and provider office staff in ascertaining the appropriate authorization based on medical necessity and the treatment plan provided.
- Performs a medical necessity check to determine if procedure and diagnosis support medical necessity.
- Ensures authorizations are obtained in accordance to network policy (any authorization not falling into policy guidelines is communicated to ordering office, patient, and manager).
- Communicates direct/indirect with insurance companies to obtain insurance verification, benefits and precertification for approval.
- Verifies additional clinical information and insurance authorizations/referrals.
- Reviews and monitors WQs/schedules to ensure that proper and accurate authorization has been received prior to patient's visit.
- Maintains compliance with benchmark data regarding accounts registered versus scheduled procedures.
- Determines estimated patient financial responsibility using insurance verification information and payer contracts and/or self-pay guidelines.
Minimum Qualifications
- High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs.
- 1 year in a healthcare setting with insurance verification/authorizations.
- Familiarity with billing procedures and payer reimbursement.
- Knowledge of patient rights and laws relative to those rights, such as HIPAA.
- Proficient in utilization management processes, standards, and managed care.
- Proficient in standard medical practices and insurance benefit structures.
Preferred Qualifications
- Associate's Degree
Requirements
- High School Diploma/GED with specialized training in insurance, coding, billing, or similar healthcare certificate programs
- 1 year in a healthcare setting with insurance verification/authorizations
- Familiarity with billing procedures and payer reimbursement
- Knowledge of patient rights and laws relative to those rights, such as HIPAA
- Proficient in utilization management processes, standards, and managed care
- Proficient in standard medical practices and insurance benefit structures
- Associate's Degree (preferred)
Company overview
Lehigh Valley Health Network (LVHN) is a major healthcare provider and hospital network based in Allentown, Pennsylvania, serving the Lehigh Valley and Northeastern Pennsylvania regions. Founded in 1899, LVHN operates as a comprehensive healthcare system with 13 hospital campuses, 28 health centers, numerous primary and specialty care physician practices, and multiple urgent care locations. The network's flagship facility, Lehigh Valley Hospital-Cedar Crest, is Pennsylvania's third-largest hospital and features the state's first Level One Trauma Center. LVHN provides a wide range of medical services including specialized institutes for cancer care, heart and vascular treatment, surgical excellence, orthopedics, and neuroscience. The network operates the third-largest heart surgery program in Pennsylvania, performing over 1,200 open-heart procedures annually, and maintains one of the state's largest cancer centers treating over 2,400 new patients each year. In August 2024, LVHN completed a merger with Jefferson Health, becoming part of a larger healthcare system with 32 hospitals and over 700 locations across Pennsylvania. Prior to the merger, LVHN was the largest employer in the Lehigh Valley metropolitan region, with approximately 20,000 employees dedicated to providing comprehensive healthcare services to the community.