LPN - Pre-Service Authorizations

This job ensures the financial security of scheduled inpatient and outpatient (excluding ED) accounts for the company's patients by obtaining/initiating prior authorization of ordered services based on payer requirements, after benefits and eligibility have been determined. Coordinates with physician and/or staff for appropriate level of care setting and essential clinical documentation to support medical necessity of services ordered and works collaboratively with Case Management to establish level of care for direct admits and inpatient stays. Also acts as a resource for the Revenue Cycle staff within Pre-Service and performs duties under general supervision and following moderately complex procedures and guidelines.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion.
 

Education

Required - Licensed Practical Nurse (LPN) diploma.

Work Experience
Required - 3 years of hospital based experience in the delivery of patient care.

Preferred - Ambulatory experience.

Certifications

Required - Current LPN license in the state of practice.

Knowledge Skills and Abilities (KSAs)

• Proficiency in using computers, software, and web-based applications.

• Effective verbal and written communication skills and ability to present information clearly and professionally.

• Excellent customer service skills and ability to gather and disseminate information with a diverse range of people, either in person or over the phone.

• Excellent interpersonal skills including and ability to work collaboratively with other departments and functional areas and handle high-pressure, difficult situations.

• Good organizational and time management skills and ability to work with minimal supervision.

• Excellent decision making, critical thinking, and analytical skills and ability to pay strong attention to detail.

• Proficiency in application of medical necessity criteria, standards of practice, and research regarding pre-certification guidelines.

• Ability to prioritize tasks and manage multiple tasks with efficiency and quality.

• Working knowledge of terminology associated with CPT and ICD-10 coding, Medicare guideline, HMO and PPO contracts and other insurance billing processes.

Job Duties

• Secures clinical documentation and performs pre-service medical necessity reviews to obtain prior authorizations.

• Maintains professional and technical knowledge and certifications.

• Ensures all regulatory requirements are met within department.

• Assists in the day-to-day operations of the department.

• Consistently supports the company and its business services goals and core values.

• Performs other duties as assigned.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.
The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.
 

Physical and Environmental Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made