Specialist, Prior Authorization

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 65000-acre lake with 1200 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

Job Summary:

The Prior Authorization Specialist is responsible for obtaining insurance authorizations for medical procedures diagnostic testing referrals medications and prescribed services to ensure timely patient care and accurate reimbursement. This role serves as a key liaison between providers patients and payers ensuring compliance with payer requirements while supporting clinic operations and revenue cycle efficiency.

Essential Functions:

• Initiate and manage prior authorization requests for procedures imaging referrals medications and other services.
• Verify patient insurance eligibility benefits and coverage requirements prior to submission.
• Review clinical documentation for completeness and collaborate with providers for medical necessity support.
• Submit authorization requests via payer portals fax or phone and track status through completion.
• Communicate approvals denials and required follow-up actions to providers staff and patients.
• Monitor turnaround times and escalate urgent or delayed cases.
• Follow up on denied authorizations and assist with appeals.
• Maintain accurate documentation in EMR and payer systems.
• Ensure compliance with payer guidelines regulatory requirements and organizational policies.
• Collaborate with scheduling clinical and billing teams to prevent delays and denials.
• Educate patients staff and providers on authorization requirements payer guidelines and coverage.
• Ensure all services have required authorizations and update patients on status.
• Coordinate peer-to-peer reviews when required by insurance.
• Notify patients and staff of insurance coverage issues or lapses.
• Assist with scheduling appointments tests and procedures as needed.
• Maintain referral and insurance records and enter referrals into systems.
• Maintain knowledge of Medicare Medicaid and commercial payer requirements.
• Identify denial trends and recommend process improvements.
• Maintain patient confidentiality in compliance with HIPAA regulations.
• Meet daily productivity and quality standards.

Non-Essential Functions:

• Position serves both internal co-workers and external customers clients and contractors.
• Access to and/or works with sensitive and/or confidential information.
• Perform other duties as assigned.

Required Qualifications:

• High school diploma or equivalent required.
• Minimum of 12 years of experience in prior authorizations medical billing or revenue cycle operations (healthcare setting preferred).
• Working knowledge of insurance payer requirements authorization processes and medical terminology.
• Proficiency with EMR systems and payer portals.
• Strong organizational skills with attention to detail and ability to manage multiple tasks.
• Excellent written and verbal communication skills.
• Ability to work independently and as part of a multidisciplinary team.

Preferred Qualifications:

• Experience in a physician practice or hospital-based clinic environment.
• Familiarity with Medicare Medicaid and commercial insurance plans.
• Certification in medical billing/coding or revenue cycle management (CPB CPC or similar).
• Experience with authorization appeals and denial resolution.

Physical and Mental Demands:

• Ability to sit for prolonged periods and work at a computer.
• Occasional standing walking bending or reaching.
• Ability to manage time-sensitive work and meet strict deadlines.
• Ability to handle frequent interruptions while maintaining focus.

Work Environment:

• Medical office or clinic environment.
• Interaction with patients providers clinical staff insurance representatives and administrative leadership.
• Standard business hours with occasional flexibility based on clinic needs.

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.