Boston Medical Centerposted 6 months ago
Full-time • Entry Level
Remote • Boston, MA
Hospitals

About the position

The Prior Authorization Specialist I is responsible for screening prior authorization requests and coordinating specialized services within the medical care management program. This role ensures compliance with performance standards while facilitating timely access to care and maximizing hospital reimbursement. The specialist will work closely with various stakeholders, including insurance representatives and healthcare providers, to manage financial clearance activities and maintain knowledge of network resources.

Responsibilities

  • Prioritizes incoming Prior Authorization requests.
  • Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines.
  • Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director.
  • Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload.
  • Supports Prior Authorization Clinicians.
  • Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller's request.
  • Identifies and informs callers of network providers, services, and available member benefits.
  • Informs provider of decision per department procedure.
  • Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.
  • Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes.
  • Maintains general understanding of applicable sections of member handbooks, and evidence of coverage.
  • Monitors accounts routed to registration and prior authorization work queues and clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with established management guidelines.
  • Maintains knowledge of and complies with insurance companies' requirements for obtaining prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance.
  • Acts as subject matter experts in navigating both the BMC and payer policies to get the appropriate approvals for scheduled care to proceed.
  • Uses appropriate strategies to underscore the most efficient process to obtaining insurance verification, authorizations and referrals.
  • Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
  • Works collaboratively with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients and any other parties to ensure that required managed care referrals and prior authorizations are obtained and appropriately recorded.
  • Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients' scheduled services.
  • Liaison between physician and payer for peer to peer review when needed.
  • Escalates accounts that have been denied or will not be financially cleared as outlined by department policy.
  • Interview patients, families or referring physicians via telephone in advance of the patient's appointment/visit to obtain all necessary information.
  • Ensure that all updated demographic and insurance information is accurately recorded in the appropriate registration systems.
  • Review all registration and insurance information in systems and reconcile with information available from insurance carriers.
  • For self-pay patients or patients with unresolved insurance, refer patients to Patient Financial Counseling.
  • Maintains confidentiality of patient's financial and medical records; adheres to the State and Federal laws regulating collection in healthcare.
  • Participates in educational offerings sponsored by BMC or other development opportunities as assigned/available.
  • Demonstrates knowledge & skills necessary to provide level of customer experience as aligned with BMC management expectations.
  • Demonstrates the ability to recognize situations that require escalation to the Supervisor.
  • Takes opportunity to know and learn other roles and processes and works together to assist with process improvement initiatives.
  • Consistently meets productivity and quality expectations to align performance with assigned roles and responsibilities.
  • Handle ACD telephone calls and emails in a timely fashion, following applicable scripting and customer service standards.
  • Regularly undergo Quality Audits to achieve the required standard.
  • Contact the Help Desk in the BMC Information Technology Department to report faulty systems or hardware.
  • Communicate with all internal and external customers effectively and courteously.
  • Attend all necessary hospital and department training as required.
  • Assists in the orientation of new personnel under the direction of a manager or Supervisor.

Requirements

  • High school diploma or GED required.
  • 3-5 years of office experience, specifically in either a high volume data entry office, customer service call center or health care office or hospital administration is required.
  • Experience using Insurance payer websites (i.e Blue Cross Blue Shield, Medicare, etc.).
  • Customer service experience preferred.
  • Experience with insurance verification, prior authorization, pre-certification and financial clearance process, or related experience.

Nice-to-haves

  • Associate's Degree or higher preferred.
  • Bilingual preferred.
  • Knowledge of basic medical terminology and ICD-9/CPT coding is helpful.
  • Knowledge of and experience within Epic is preferred.

Benefits

  • Health insurance coverage
  • Dental insurance coverage
  • Vision insurance coverage
  • 401k benefit for retirement savings plan
  • Paid holidays
  • Paid time off (PTO)
  • Flexible scheduling options
© 2024 Teal Labs, Inc
Privacy PolicyTerms of Service