Prior Authorization Specialist

Mass General Brigham Health Plan, Inc.; Boston (MA); Hybrid; USD 50,000 - 80,000; Full time

Job summary

Join a forward-thinking healthcare organization as a Prior Authorization Specialist, where you will play a crucial role in ensuring exceptional patient experiences by securing necessary authorizations for medical services. This hybrid position offers the opportunity to work closely with various healthcare professionals while managing complex patient care plans and navigating insurance requirements. You will be instrumental in supporting the organization’s financial health, contributing to approximately $4 billion in revenue. If you are passionate about patient care and thrive in a collaborative environment, this role is perfect for you.

Qualifications

• 2+ years of experience in hospital settings or related medical institutions.
• Knowledge of insurance and managed care authorization requirements preferred.

Responsibilities

• Secure authorizations for medical and surgical admissions across entities.
• Act as a liaison between physicians, insurance companies, and Patient Financial Services.

Skills

Customer Service Skills

Communication Skills

Problem-Solving Skills

Organizational Skills

Knowledge of Insurance Authorization

Ability to Work Independently

Education

Bachelor's Degree

High School Diploma

Tools

EPIC Clinical System

Ontrac Work Lists

Job description

Prior Authorization Specialist page is loaded

Prior Authorization Specialist

Apply remote type Hybrid locations Boston-MA time type Full time posted on Posted 2 Days Ago job requisition id RQ4007109 Site: The Brigham and Women's Hospital, Inc.

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

The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating exceptional patient experience, by securing authorizations for all scheduled services related to medical and surgical admissions across entities, including BWH OR procedures, BWFH OR procedures, FXB OR procedures, and BWH/BWFH Endoscopy Suite procedures in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. The PAS is also responsible for securing authorizations for all Emergency and Urgent admissions to BWH and BWFH and for all Infusion Clinic Services for BWH and BWFH in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. This is a role that is critical to the organization’s financial health, where responsibilities account for approximately $4 Billion in revenue per fiscal year.

• Maintains expert-level knowledge about the industry; utilizes to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as aligned with organizational values and mission.
• Acts as subject matter expert and guide to a broad employee base, particularly providers, to educate and communicate on requirements, processes, and adjustments needed throughout the patient care journey.
• Interacts directly with EPIC Auth/Cert, Registration, and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, which includes, but is not limited to, appropriate CPT Procedure and Diagnosis codes, rendering Physician(s), level of care, and facility, i.e., across entities (BWH, BWFH, FXB, etc.).
• Uses independent judgment to make knowledgeable decisions in organizing with physician and office to respond to Medical Insurance inquiries and resolving conflicts concerning approval for surgical procedures in the OR.
• Consults with all levels of Hospital professionals, administrative and support staff, as well as patients, and representatives of other organizations where advanced expertise in communications is necessary to lead with tact, inclusivity, patience, and respect while maintaining confidentiality and achieving consensus with the lens of exceptional patient experience.
• Interacts directly with EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization, e.g., clinical office notes, radiology reports, lab tests and results, PT/OT notes, imaging results, and photos.
• Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist, e.g., predetermination of medical necessity, need for out-of-network plan auth required in addition to the service/procedural auth, etc.
• Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and/or guidelines.
• Updates, obtains, and/or verifies all pertinent data necessary to complete required registration, admission, demographic, and financial information ensuring both timely access and accurate billing.
• Ability to identify incomplete clinical documentation that is needed to obtain approval for services.
• Compiles, uploads, and submits all the above clinical information from Epic required to obtain preadmission approvals and precertification via the Medical Insurance Payer Portals.
• Determines when problematic preadmissions must be referred to Sr. Manager and/or Director.
• Acts as liaison between physicians, insurance companies, and Patient Financial Services across multiple campuses.
• Monitors pending cases to ensure that approvals are obtained before admission or visit.
• Advises uninsured and underinsured patients regarding available programs.
• Makes appropriate referrals to the Patient Financial Services Department in a timely manner.
• Reviews and follows-up on all emergency and unscreened admissions as soon as possible, within 24 business hours of admission at the latest.
• Follows all cases throughout the duration of the admission, working with the Utilization Review (UR) Department.
• Reviews RTE eligibility system in EPIC throughout admission for any Payer changes or discrepancies.
• Reviews cases daily for patient class changes.
• Scans authorization-related information into Epic Media Manager and documents notes in accordance with QA Metrics.
• Works closely with the Authorization Denials Team to avert write-offs by researching cases and providing back-up documentation for possible prior auth appeals.
• Stays current with Payer changes in authorization requirements and restrictions.
• Maintains a daily workflow of Ontrac work lists and keeps Epic auth/cert fields and notes updated.
• Maintains patient confidentiality and privacy by accessing patient information only to the extent necessary to fulfill assigned duties.
• Adheres to Customer Service Standards (Service Excellence).

Qualifications

• Bachelor’s degree or equivalent preferred; high school diploma required.
• 2+ years’ experience in hospital settings such as Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing, or at a related type of medical institution or medical payer.
• Knowledge of insurance and/or managed care authorization requirements is preferred.
• Knowledge of revenue cycle particularly regarding insurance reimbursement and managed care authorization and referral requirements.
• Technical knowledge of specific legal and regulatory requirements and an understanding of complex third-party and medical assistance policies and procedures.
• Knowledge of the hospital information system with emphasis on registration and insurance verification, and accounts receivables programs.

Interactions/Interpersonal Skills:

• Demonstrated excellent customer service abilities.
• Proficiency in oral and written communication.
• Heightened ability to effectively interact with various levels of the organization.
• Ability to work independently, with minimal supervision.
• Able to identify when something needs to be escalated to Senior Management.
• Commitment to collaborating within a functional team.
• Adeptness in assessing and solving problems, excellent organizational skills, and ability to multi-task and prioritize.
• Possess a continuous and nimble learning mindset.
• Demonstrated ability to enact good judgment, tact, sensitivity, and the ability to function in a fast-paced, constantly changing environment.
• Ability to maintain confidentiality regarding patients, their medical histories, demographic and fiscal information, etc.

Additional Job Details (if applicable)

Remote Type

Hybrid

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement:

The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer.