Prior Authorization Associate

PN Access and Authorizations

Full Time

Day Shift

7:30am - 4pm M-F

Consistently named best hospital, Lexington Medical Center anchors an expansive health care network that includes nearly 600 physicians and advanced practice providers at nearly 80 locations across the Midlands of South Carolina, making it the region’s third largest employer. From general medicine and orthopaedics to oncology, cardiology and neurosurgery, these dedicated professionals combine the highest quality care with advanced medicine and state-of-the-art technology to help patients achieve the best possible outcomes. Its postgraduate medical education programs include family medicine and transitional year residencies.

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.

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 salaryEmployee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistanceLHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employmentTuition reimbursementStudent loan forgiveness

Equal Opportunity Employer

It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC 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. LMC 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.

Nearest Major Market: Columbia

Nearest Secondary Market: South Carolina