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.

Job description

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.

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.

Requirements

High School Diploma or Equivalent
6 months of referral and/or authorization experience
Strong Medical Terminology and Insurance Knowledge
Knowledge of ICD-10 and CPT Coding

Benefits

Medical, Dental & Vision
Life Insurance
Flexible Spending Accounts
403(b) Matching
Adoption Assistance
Short-Term Disability
Long-Term Disability
Tuition Reimbursement
Student Loan Forgiveness

Company overview

Lexington Health is a comprehensive healthcare network serving the Midlands region of South Carolina, formerly known as Lexington Medical Center. Established in 1971 as Lexington County Hospital with just 125 beds and 250 employees, the organization has grown into a major regional healthcare system. Today, Lexington Health operates a 607-bed teaching hospital that serves as the flagship facility, along with six community medical and urgent care centers, nearly 80 physician practices, and employs more than 9,000 healthcare professionals. The network is the only locally owned, independent healthcare system in the Midlands region and maintains an affiliation with Duke University School of Medicine. Lexington Health provides a full spectrum of medical services including cardiovascular care, cancer treatment through its Duke Cancer Institute affiliation, women's services delivering over 4,000 babies annually, emergency care treating more than 105,000 patients each year, and specialized programs in orthopedics, neurology, and other medical specialties. The organization has earned numerous accolades including being ranked as the #1 hospital in Columbia for four consecutive years and achieving Magnet with Distinction recognition from the American Nurses Credentialing Center, making it the only hospital in South Carolina with this distinction.