Prior Authorization Specialist I - Per Diem

Boston Medical Center Health System; Boston (MA); On-site; USD 40,000 - 70,000; Part time

Job summary

An established industry player is seeking a dedicated Prior Authorization Specialist to join their Revenue Cycle Patient Access team. This remote role is vital for managing financial clearance activities, ensuring timely patient access, and adhering to quality standards. The ideal candidate will excel in a fast-paced environment, demonstrating strong customer service skills and a thorough understanding of insurance verification and prior authorization processes. If you thrive in a collaborative setting and are passionate about delivering excellent healthcare services, this opportunity is perfect for you.

Qualifications

• 4-5 years of office experience in data entry or healthcare administration.
• Experience with insurance verification and financial clearance processes.

Responsibilities

• Prioritize and process incoming authorization requests efficiently.
• Educate stakeholders on authorization requirements and processes.
• Collaborate with practices to secure necessary authorizations.

Skills

Data Entry

Customer Service

Insurance Verification

Prior Authorization

Communication Skills

Multitasking

Medical Terminology

Bilingual

Education

High School Diploma or GED

Associate’s Degree or higher

Tools

Epic

Microsoft Suite

CCMS

Facets

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 linkages to members and providers. Authorizes specific services under supervisor guidance, following departmental guidelines. Forwards requests requiring clinical review to clinicians and handles provider and departmental inquiries via ACD lines.

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 supports timely patient access and hospital reimbursement, adhering to quality and productivity standards. Reports to the Patient Access Supervisor and collaborates with insurance representatives, patients, physicians, and other stakeholders. This is a remote position.

Position: Prior Authorization Specialist I - Per Diem

Department: Insurance Verification

Schedule: Part Time, Per Diem

ESSENTIAL RESPONSIBILITIES / DUTIES:

1. Prioritize and process incoming authorization requests.
2. Refer complex requests requiring clinical judgment to appropriate clinicians or managers.
3. Meet or exceed productivity and turnaround time metrics while managing a full caseload.
4. Support clinicians with authorization processes.
5. Answer calls, verify member eligibility, and document information in CCMS or Facets.
6. Inform callers about network providers, services, and benefits.
7. Communicate decisions to providers as per department protocols.
8. Resolve escalated inquiries from members or providers.
9. Educate stakeholders on authorization requirements and processes.
10. Maintain knowledge of member handbooks and coverage evidence.
11. Monitor and clear work queues, obtaining all necessary financial clearance information.
12. Ensure compliance with insurance requirements for prior authorizations and referrals.
13. Navigate BMC and payer policies to secure necessary approvals for scheduled care.
14. Utilize online databases, electronic correspondence, faxes, and calls for verification and authorization.
15. Document referral and authorization details in Epic prior to scheduled services.
16. Collaborate with practices, physicians, insurance carriers, and patients to obtain and record authorizations, ensuring linkage to appointments.
17. Coordinate with patients, providers, and departments to secure necessary permissions before services.
18. Serve as liaison for peer-to-peer reviews when needed.
19. Escalate denied or unfinancially cleared accounts per policy.
20. Interview patients and providers to gather necessary information for reimbursement and compliance.
21. Update demographic and insurance data accurately in registration systems.
22. Reconcile insurance information and contact patients for clarifications as needed.
23. Refer unresolved or self-pay patients to Financial Counseling.
24. Maintain confidentiality and comply with legal and organizational policies.
25. Participate in training and process improvement initiatives.
26. Meet productivity and quality expectations consistently.
27. Handle calls and emails professionally, following scripts and standards.
28. Report system issues to IT Help Desk and notify supervisors of unresolved problems.
29. Communicate effectively with all stakeholders.
30. Attend required training sessions and assist in onboarding new personnel.
31. Perform other duties as assigned.

JOB REQUIREMENTS

Education:

• High school diploma or GED required.
• Associate’s Degree or higher preferred.

Certificates, Licenses, Registrations:

None required.

Experience:

• 4-5 years of office experience in high-volume data entry, customer service call centers, or healthcare administration.
• Experience using insurance payer websites.
• Customer service experience preferred.
• Experience with insurance verification, prior authorization, pre-certification, and financial clearance processes.

Knowledge, Skills & Abilities:

• Bilingual preferred.
• High accuracy processing with a 95% or greater success rate.
• Ability to prioritize and meet turnaround times.
• Effective collaboration and communication skills.
• Thorough understanding of the financial clearance process and insurance policies.
• Knowledge of medical terminology and coding is helpful.
• Strong interpersonal skills for relationship building.
• Self-directed, organized, and capable of multitasking.
• Decisive under pressure with good judgment and confidentiality.
• Proficiency with Epic and ancillary systems; Microsoft Suite skills.

Equal Opportunity Employer/Disabled/Veterans