Prior Authorization Specialist

Lake Cumberland Regional Hospital
 

Who We Are:

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Lake Cumberland Regional Hospital is a modern, state-of-the-art 295-bed acute care facility, offering an advanced neurosurgery program with Spine Center accreditation amongst other specialty services. 

Where We Are:

The City of Somerset blends southern hospitality with abundant recreational opportunities including a 65,000-acre lake with 1,200 miles of shoreline.  Somerset is host to nationally recognized, high quality performing and visual arts, concerts and other special events to the community.

Why Choose Us:

• Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
• Competitive Paid Time Off / Extended Illness Bank package for full-time employees
• Employee Assistance Program - mental, physical, and financial wellness assistance
• Tuition Reimbursement/Assistance for qualified applicants
• Professional Development and Growth Opportunities
• And much more...

Position Summary: 

The Prior Authorization Specialist works with departments and insurance companies to obtain the necessary pre-certifications and authorizations for services ordered/scheduled. Once received these are recorded in Paragon to ensure appropriate billing. The Prior Authorization Specialist maintains a high level of understanding of insurance companies and billing authorization requirements.

Education:  Highschool diploma or equivalent

Required Skills:

• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Essential Functions:

Contacts insurance carriers to obtain benefit coverage, policy limitations, authorization/notification, and pre-certifications for identified patients. 

Follows up with physician offices, financial counselors, patients, and third-party payers to complete the pre-certification process.

Collaborates with Supervisor, internal departments and clinical staff as needed to provide account status updates, coordinate the resolution of issues, and appeal denied authorizations.
Ensures information obtained is complete and accurate, applying acquired knowledge of Medicare, Medicaid, and third-party payer requirements/on-line eligibility systems.
Educates patients, staff and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements, and insurance related changes or trends.
Ensures all services have prior authorizations and updates patients on their preauthorization status. 

Coordinates peer to peer review if required by insurance.
Notifies patient accounts staff/patients of insurance coverage lapses, and self-pay patient status. 

May notify ordering providers if authorization/certification is denied.
May coordinate scheduling of patient appointments, diagnostic and/or specialty appointments, tests and/or procedures.
Maintains files for referral and insurance information and enters referrals into the system.
Maintains knowledge of and reference materials of the following: Medicare, Medicaid and third-party payer requirements, guidelines and policies, insurance plans requiring pre-authorization and a list of current accepted insurance plans.
Serves as an expert for peers across the patient access continuum.
Meets daily productivity and quality standards associated with job requirements.
Performs other job-related responsibilities as requested.

EEOC Statement

Lake Cumberland Regional Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.