Prior Authorization Associate

Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals, and Lexington Medical Center—a 607-bed teaching hospital in West Columbia, South Carolina. Recognized as one of the Best Places to Work in Healthcare by Modern Healthcare and the first in the state to achieve Magnet with Distinction status for nursing excellence, Lexington Health delivers over 4,000 babies annually, performs more than 34,000 surgeries, and is the region’s third-largest employer. The network also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Postgraduate medical education programs include family medicine, transitional year residencies, and an informatics fellowship.

About the role

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 and verifies all pertinent clinical information is submitted for accurate processing. Documents all information within the referral record and chart in Epic, including approvals, denials, peer-to-peers, and pending authorizations.

Responsibilities

• Understands the referral process start to finish and acknowledges authorization as a critical step.
• Meets monthly authorization volume and quality standards.
• Reviews patient charts in Epic, submits appropriate clinical information for authorization to the correct payer/third-party vendor, obtains final determination, and enters details into Epic.
• Utilizes Experian RTA system to obtain authorization and verifies completion within the system.
• Communicates authorization updates and status changes to relevant departments.
• Relays peer-to-peer requests to PN practices for providers/clinical staff to complete for payer authorization.
• Partners with LMC departments and insurance companies to ensure quality care through the authorization process prior to patients' date of service.
• Escalates difficult issues, problems, questions, and process improvement suggestions to management.
• Collaborates with the team to ensure timely processing of authorizations.
• Participates in team problem-solving activities, focusing on production and quality.
• Performs other duties as assigned.

Requirements

• Minimum Education: High School Diploma or Equivalent
• Minimum Years of Experience: 6 months of referral and/or authorization experience
• Strong Medical Terminology and Insurance Knowledge
• Knowledge of ICD-10 and CPT Coding

Benefits

• Day-one medical, dental, and life insurance benefits
• Health care and dependent care flexible spending accounts (FSAs)
• 403(b) match plan with dollar-for-dollar employer match up to 6% (eligible day one)
• Employer-paid life insurance equal to 1x salary
• Optional supplemental life insurance up to 3x salary at low-cost premiums
• Adoption assistance
• Employer-paid short-term and long-term disability coverage after 90 days of eligible employment
• Tuition reimbursement
• Student loan forgiveness

Schedule

Full-time, day shift: Monday–Friday, 8:00 AM–4:30 PM