Manager, Prior Authorization and Referrals Healthcare At Home

Massachusetts General Hospital; Somerville (MA); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Manager for Prior Authorization and Referrals to lead a dynamic team. This role involves overseeing day-to-day operations, ensuring efficient patient experiences, and collaborating with key stakeholders to enhance processes and technology. The ideal candidate will possess strong operational management skills and a comprehensive understanding of healthcare practices. Join a forward-thinking organization that values teamwork and innovation, and make a significant impact in improving patient access and experience across multiple facilities.

Qualifications

• Minimum of 2 years relevant healthcare experience required.
• Strong operational management and process optimization skills.

Responsibilities

• Oversee day-to-day activities in prior authorization and referrals.
• Ensure smooth patient experiences while collecting accurate information.

Skills

Operational management

Process optimization

Personnel management

Communication skills

Customer service

Insurance knowledge

Call center technology

Analytical skills

Education

Bachelor's degree in Healthcare Administration

Bachelor's degree in Business Administration

Job description

Site: Mass General Brigham Incorporated

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Provides leadership, efficient, effective oversight of day-to-day activities and teams in the prior authorization and referrals space. In partnership with key stakeholders, the Manager, Prior Authorization and Referrals, contributes and supports enterprise prior authorization and referral strategy, and continuously works to improve people, process, and technology across the function. The Manager provides leadership and direct supervisory support of team members.
The prior authorization and referrals team is responsible for insurance validation & verification, capture of insurance referrals and prior authorizations, updating patient data in Epic, and work queue management functions. Through their leadership and oversight, the Manager, Prior Authorization and Referrals will work to ensure that patients receive a smooth and efficient experience while collecting accurate insurance and related information while facilitating the necessary administrative procedures to ensure a clean claim with complete data. Provides insight and incorporates denials prevention and payer requirements into workflow to minimize revenue leakage. For the Manager, Prior Authorization and Referrals in the Healthcare At Home division, this role also works closely with the Patient Financial Services team on denial appeals and write off decisions.

Qualifications

Education

• Bachelor's degree preferred with discipline in Healthcare Administration, Management, Finance, Business Administration, or related field.

Work Experience

• Minimum of 2 years prior relevant healthcare experience, registration and/or managed care referral experience required.

Skills/Abilities/Competencies:

• Demonstrates competency and leadership experience in a large, complex organization with multiple locations.
• Strong operational management and process/technology optimization skills.
• Excellent personnel management and organizational management skills - including written and oral communication, relationship management, customer service, and organization.
• Comprehensive knowledge of patient registration contractual terms and requirements, health insurance practices, and industry standards.
• Familiarity with various call center technologies, including but limited to; workforce management, ACD call routing and reporting and quality monitoring.
• Communicate and operate effectively within and between system functions.
• Undertake an enterprise-wide perspective with respect to their role.
• Manage upwards, elevating key risks and opportunity areas to Patient Access & Experience.
• Build consensus and lead change within a large matrix organization with multiple stakeholder groups.
• Exercise judgement in dealing with sensitive, confidential information

Leadership Impact & Problem Solving

• Develops, motivates and retains front-line team members.
• Oversees the recruiting, hiring, orientation and integration of new team members into the team.
• Acts as a role model demonstrating commitment to Mass General Brigham's goals, philosophies, values and vision.
• Empowers all members of the team to make appropriate front-line decisions to resolve issues for customers at point of contact.
• Sets high standards of professional behavior, corporate responsibility and integrity.
• Supports team members in activities that promote personal and professional development
• Aligns prior authorization and referral deployment with Mass General Brigham's enterprise strategy, standardizing processes across all enterprise facilities.
• Drives focus, efficiency, and role clarity across teams focused on prior authorizations and referrals, patient satisfaction, work queues and call-center activities.
• Foresees and mitigates any significant risks in the work (Ex. denials, delays, work queue backlog, Medicaid conversions).

• Consistently monitors progress and provides feedback on team member performance as well as service level targets. Ensures the timely administration of coaching and corrective action for less than acceptable performance by staff members. Ensures consistent application of departmental and health system policies and procedures.
• Completes performance appraisals for direct reports in a timely manner, and works with team members to set achievable performance and development goals.

• Identifies system and operational problems through analysis of current processes. Recommends solutions and improvements.
• Embraces change and articulates the opportunities changes and growth bring to the team.

Financial Performance

• Assists in the development of and adherence to the approved annual budget and demonstrates cost effective delivery of department services.

Operational Performance

• Monitors and manages productivity relative to teamwork queues to minimize denials, DNFB and Claim errors.
• Analyzes trends and root causes and solves complex operational issues (i.e., raised customer calls, identifies optimizations).
• Adjudicates and supports efficient and effective operational policies, standard processes, and technologies.
• Facilitates projects and conversations with MGB departments and stakeholders to share and develop standard processes.
• Recommends and engages with third party vendors where reason for performance exists.
• Oversees staff volume management, flexing resources across work queues based on volume demands.

Key Interactions

• Patient Access and Experience Team | Collaborate with department leadership, to help influence PA&E strategy development.
• Health Care at Home (if applicable) | Partners with Health Care at Home leadership to ensure alignment with organizational goals
• Ambulatory and Hospital Operations Management| Partners with MGB leaders at sites and in ambulatory to ensure seamless patient experience and denial prevention
• Payer Services Team | Assist Payer Services with identified payer issues
• Denials Prevention Team | review denial prevention outcomes and strategies and implement process improvements

Decision Rights

Accountable

• Ensured productivity, efficiency and accuracy of assigned work.

Responsible

• Identify and Monitor Patient Access & Experience Key Performance Indicators (within respective team).
• Prioritize Patient Access & Experience Resources (within respective team).
• Manage day to day operations of prior authorization and referrals team.

Consulted

• Define Patient Access & Experience Goals.
• Define Policies and Practices for the Patient Access & Experience Team.
• Develop Revenue Cycle Operational Budgets.

Informed

• Develop Enterprise-Wide Revenue Cycle Strategy.

Other duties and responsibilities as assigned.

Additional Job Details (if applicable)

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement:

Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.