Prior Authorization Specialist I (Part-Time) - Patient Access Services

Boston Medical Center; United States; Remote; USD 35,000 - 50,000; Part time

Job summary

A leading healthcare provider is seeking a Prior Authorization Specialist I to manage financial clearance activities and ensure compliance with healthcare delivery standards. This remote part-time role involves collaboration with various stakeholders to facilitate timely access to care and maximize hospital reimbursement. The ideal candidate should possess strong organizational and communication skills, with a background in healthcare administration.

Qualifications

• 4-5 years in high-volume office, customer service, or healthcare administration.
• Familiarity with insurance websites and verification processes.

Responsibilities

• Prioritize and process requests for prior authorization.
• Coordinate resolution of escalated inquiries from members or providers.
• Ensure compliance with insurance requirements for prior authorizations.

Skills

Bilingual

Collaboration

Communication

Organizational Skills

Education

High school diploma or GED

Associate’s degree

Tools

Epic

Microsoft Office

Job description

POSITION SUMMARY:

Responsible for screening prior-authorization and coordinating specialized services requests within the medical care management program, including inpatient, outpatient, and ancillary services. Ensures compliance with policies and procedures to meet performance and compliance standards, promoting cost-effective and appropriate healthcare delivery. Maintains current knowledge of network resources for referrals and linkage to members and providers. Authorizes specified services under supervision, forwards requests to clinicians for review, and handles provider and department inquiries via ACD calls.

The Prior Authorization Specialist is part of the Revenue Cycle Patient Access team, managing financial clearance activities such as pre-registration, insurance verification, and obtaining referrals or precertification numbers. The role facilitates timely access to care and maximizes hospital reimbursement, adhering to quality and productivity standards. It involves collaboration with insurance representatives, patients, physicians, and hospital staff. This is a remote position.

Position: Prior Authorization Specialist I

Department: Patient Access Services

Schedule: Part Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

1. Prioritize incoming requests for prior authorization.
2. Process requests, including authorizations, as per departmental policies.
3. Refer complex requests requiring clinical judgment to clinicians or management.
4. Meet or exceed productivity and turnaround time metrics.
5. Support clinicians with administrative tasks.
6. Answer calls, verify eligibility, and enter data into CCMS or Facets.
7. Inform callers about network providers, services, and benefits.
8. Communicate decisions to providers as per procedures.
9. Coordinate resolution of escalated inquiries from members or providers.
10. Educate members and providers on authorization processes.
11. Maintain knowledge of member handbooks and coverage evidence.
12. Monitor and clear work queues, obtaining all necessary authorization details.
13. Ensure compliance with insurance requirements for prior authorizations and referrals.
14. Navigate payer policies to secure approvals for scheduled care, acting as a liaison among clinicians, payers, and patients.
15. Use various strategies and systems for verification and authorization processes.
16. Document all authorizations in Epic before scheduled services.
17. Collaborate with practices, physicians, and payers to ensure proper authorizations are obtained and recorded.
18. Work with patients and providers to gather necessary information and permissions.
19. Escalate denied or unresolved accounts per policy.
20. Interview patients and families to gather demographic and financial information prior to services.
21. Update demographic and insurance data accurately in registration systems.
22. Reconcile insurance information and contact patients for clarifications as needed.
23. Refer self-pay or unresolved insurance cases to Financial Counseling.
24. Maintain confidentiality and adhere to legal and organizational policies.
25. Participate in educational and process improvement initiatives.
26. Meet productivity and quality standards consistently.
27. Handle calls and emails professionally, following scripting and customer service standards.
28. Participate in quality audits and report system issues to IT.
29. Communicate effectively with internal and external stakeholders.
30. Attend training and assist in onboarding new personnel.
31. Perform additional duties as assigned.

JOB REQUIREMENTS

Education: High school diploma or GED required; Associate’s degree preferred.

Certificates, Licenses, Registrations: None required.

Experience: 4-5 years in high-volume office, customer service, or healthcare administration; familiarity with insurance websites and verification processes; customer service experience preferred.

Knowledge, Skills & Abilities: Bilingual preferred; high accuracy in high-volume processing; strong collaboration, communication, and organizational skills; knowledge of medical terminology, ICD-9/CPT coding, Epic, and insurance processes; proficiency in Microsoft Office; ability to maintain confidentiality and make independent decisions under pressure.

Equal Opportunity Employer/Disabled/Veterans