Brigham and Women's Hospital
Prior Authorization Specialist
Brigham and Women's Hospital, Somerville, Massachusetts, us, 02145
Overview
The Prior Authorization Specialist (PAS) is responsible for facilitating an exceptional patient experience by securing authorizations for all scheduled services related to medical and surgical admissions across entities (BWH OR procedures, BWFH OR procedures, FXB OR procedures, and BWH/BWFH Endoscopy Suite procedures) and for all Emergency and Urgent admissions to BWH and BWFH, as well as all Infusion Clinic Services for BWH and BWFH. This role supports standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. This position contributes to the organization’s financial health, with responsibilities that impact approximately $4 billion in revenue per fiscal year.
Qualifications
A bachelor’s degree or equivalent is preferred; a high school diploma is required.
2+ years of experience in hospital settings (e.g., Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing) or related medical institution or medical payer.
Knowledge of insurance and/or managed care authorization requirements is preferred.
Knowledge of revenue cycle, particularly insurance reimbursement, managed care authorization, and referral requirements.
Technical knowledge of legal and regulatory requirements and understanding of complex third-party and medical assistance policies and procedures.
Knowledge of the hospital information system with emphasis on registration, insurance verification, and accounts receivable programs.
Responsibilities
Maintain expert-level knowledge about the industry and apply it to manage payment models of complex patient care plans while facilitating an exceptional patient experience aligned with organizational values and mission.
Act as subject-matter expert and guide to a broad employee base, particularly providers, to educate and communicate requirements, processes, and adjustments needed throughout the patient care journey.
Interact directly with EPIC Auth/Cert, Registration, and Referral Shell, entering data accurately to coordinate all elements required for payment of services, including appropriate CPT and Diagnosis codes, rendering Physician(s), level of care, and facility, across entities (BWH, BWFH, FXB, etc.). Coordinate with DFCI and/or Boston Children’s Hospital care under special agreements when needed.
Use independent judgment to respond to Medical Insurance inquiries and resolve conflicts concerning approval for surgical procedures in the OR.
Consult with hospital professionals, administrative and support staff, patients, and other organizations as needed to lead with tact, inclusivity, patience, and respect while maintaining confidentiality and achieving consensus toward excellent patient experience.
Interact with EPIC Clinical System to extract clinical data (office notes, radiology reports, labs, PT/OT notes, imaging, and related items) to submit to Medical Insurance for authorization. Different surgeries and insurers have varying information needs.
Contact insurance companies and managed care plans to verify coverage and determine pre-admission requirements, predetermination of medical necessity, and out-of-network authorizations when required.
Determine eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and state/federal regulations; understand contracted payers and required level and type of care.
Update and verify data for registration, admission, demographic, and financial information to ensure timely and accurate billing; data is entered from multiple sources.
Identify missing clinical documentation and coordinate with physicians/clinicians and office staff to obtain complete information for authorization.
Compile, upload, and submit clinical information from Epic required for preadmission approvals and precertification via Medical Insurance Payer Portals.
Escalate complex cases to Sr. Manager/Director when legal, financial, or policy-exclusion issues arise.
Act as a liaison between physicians, insurance companies, and Patient Financial Services across multiple campuses.
Monitor pending cases to obtain approvals before admission; inform offices of any additional clinical requests and necessary therapies for certain cases (e.g., Orthopedic or Neuro Spine).
Advise uninsured/underinsured patients about available programs; refer to Patient Financial Services as needed to secure coverage and submit authorization.
Advise on patient liability estimates and coordinate with PFS, practice staff, and patients/families to explain expectations for liability and collection of amounts due.
Review and follow up on emergency and unscreened admissions promptly (within 24 business hours) to minimize financial risk.
Maintain ongoing communication with Utilization Review and Payer throughout admission for authorization days and to address denials with in-house peer-to-peer review when needed.
Review RTE eligibility in EPIC for payer changes or discrepancies and follow up on new authorizations as payer changes mid-admission.
Review daily for patient class changes (e.g., outpatient to inpatient) and request authorization updates as needed.
Review Ontrac list for exceptions and monitor expected surgery dates, payer changes, and high-risk/high-dollar accounts.
Scan authorization-related information into Epic Media Manager and document notes per QA metrics.
Collaborate with the Authorization Denials Team to avert write-offs by researching cases and preparing backup documentation for possible prior authorization appeals.
Stay current with payer changes in authorization requirements and restrictions (e.g., CPT codes requiring authorization).
Maintain a daily Ontrac workflow and keep Epic auth/cert fields and notes updated before, during, and after service until final authorization is secured for billing.
Maintain patient confidentiality and privacy in accordance with policy and law.
Adhere to Customer Service Standards by demonstrating professionalism and responsiveness to patients, visitors, and staff.
Interactions/Interpersonal Skills
Excellent customer service abilities with awareness of sensitivities related to patient experience and hospital mission.
Proficiency in oral and written communication.
Ability to interact effectively with various levels of the organization and manage challenging communications with a diverse set of customers.
Ability to work independently with minimal supervision.
Know when to escalate to Senior Management from case level to thematic level.
Collaborative team player focused on efficiency and quality to meet departmental goals.
Strong problem-solving, organizational, multitasking, and prioritization skills.
Continuous learning mindset to remain a trusted subject matter expert.
Good judgment, tact, sensitivity, and ability to work in a fast-paced, changing environment.
Maintain confidentiality of patient information and data.
Additional Information Please note:
This position is 100% onsite at Assembly Row for the probation and training period (minimum 90 days). A hybrid schedule is not guaranteed after this period and depends on departmental needs.
The Brigham and Women’s Hospital, Inc. 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 by law. Reasonable accommodations are provided for applicants with disabilities during the job application or interview process and to perform essential job functions.
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Qualifications
A bachelor’s degree or equivalent is preferred; a high school diploma is required.
2+ years of experience in hospital settings (e.g., Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing) or related medical institution or medical payer.
Knowledge of insurance and/or managed care authorization requirements is preferred.
Knowledge of revenue cycle, particularly insurance reimbursement, managed care authorization, and referral requirements.
Technical knowledge of legal and regulatory requirements and understanding of complex third-party and medical assistance policies and procedures.
Knowledge of the hospital information system with emphasis on registration, insurance verification, and accounts receivable programs.
Responsibilities
Maintain expert-level knowledge about the industry and apply it to manage payment models of complex patient care plans while facilitating an exceptional patient experience aligned with organizational values and mission.
Act as subject-matter expert and guide to a broad employee base, particularly providers, to educate and communicate requirements, processes, and adjustments needed throughout the patient care journey.
Interact directly with EPIC Auth/Cert, Registration, and Referral Shell, entering data accurately to coordinate all elements required for payment of services, including appropriate CPT and Diagnosis codes, rendering Physician(s), level of care, and facility, across entities (BWH, BWFH, FXB, etc.). Coordinate with DFCI and/or Boston Children’s Hospital care under special agreements when needed.
Use independent judgment to respond to Medical Insurance inquiries and resolve conflicts concerning approval for surgical procedures in the OR.
Consult with hospital professionals, administrative and support staff, patients, and other organizations as needed to lead with tact, inclusivity, patience, and respect while maintaining confidentiality and achieving consensus toward excellent patient experience.
Interact with EPIC Clinical System to extract clinical data (office notes, radiology reports, labs, PT/OT notes, imaging, and related items) to submit to Medical Insurance for authorization. Different surgeries and insurers have varying information needs.
Contact insurance companies and managed care plans to verify coverage and determine pre-admission requirements, predetermination of medical necessity, and out-of-network authorizations when required.
Determine eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and state/federal regulations; understand contracted payers and required level and type of care.
Update and verify data for registration, admission, demographic, and financial information to ensure timely and accurate billing; data is entered from multiple sources.
Identify missing clinical documentation and coordinate with physicians/clinicians and office staff to obtain complete information for authorization.
Compile, upload, and submit clinical information from Epic required for preadmission approvals and precertification via Medical Insurance Payer Portals.
Escalate complex cases to Sr. Manager/Director when legal, financial, or policy-exclusion issues arise.
Act as a liaison between physicians, insurance companies, and Patient Financial Services across multiple campuses.
Monitor pending cases to obtain approvals before admission; inform offices of any additional clinical requests and necessary therapies for certain cases (e.g., Orthopedic or Neuro Spine).
Advise uninsured/underinsured patients about available programs; refer to Patient Financial Services as needed to secure coverage and submit authorization.
Advise on patient liability estimates and coordinate with PFS, practice staff, and patients/families to explain expectations for liability and collection of amounts due.
Review and follow up on emergency and unscreened admissions promptly (within 24 business hours) to minimize financial risk.
Maintain ongoing communication with Utilization Review and Payer throughout admission for authorization days and to address denials with in-house peer-to-peer review when needed.
Review RTE eligibility in EPIC for payer changes or discrepancies and follow up on new authorizations as payer changes mid-admission.
Review daily for patient class changes (e.g., outpatient to inpatient) and request authorization updates as needed.
Review Ontrac list for exceptions and monitor expected surgery dates, payer changes, and high-risk/high-dollar accounts.
Scan authorization-related information into Epic Media Manager and document notes per QA metrics.
Collaborate with the Authorization Denials Team to avert write-offs by researching cases and preparing backup documentation for possible prior authorization appeals.
Stay current with payer changes in authorization requirements and restrictions (e.g., CPT codes requiring authorization).
Maintain a daily Ontrac workflow and keep Epic auth/cert fields and notes updated before, during, and after service until final authorization is secured for billing.
Maintain patient confidentiality and privacy in accordance with policy and law.
Adhere to Customer Service Standards by demonstrating professionalism and responsiveness to patients, visitors, and staff.
Interactions/Interpersonal Skills
Excellent customer service abilities with awareness of sensitivities related to patient experience and hospital mission.
Proficiency in oral and written communication.
Ability to interact effectively with various levels of the organization and manage challenging communications with a diverse set of customers.
Ability to work independently with minimal supervision.
Know when to escalate to Senior Management from case level to thematic level.
Collaborative team player focused on efficiency and quality to meet departmental goals.
Strong problem-solving, organizational, multitasking, and prioritization skills.
Continuous learning mindset to remain a trusted subject matter expert.
Good judgment, tact, sensitivity, and ability to work in a fast-paced, changing environment.
Maintain confidentiality of patient information and data.
Additional Information Please note:
This position is 100% onsite at Assembly Row for the probation and training period (minimum 90 days). A hybrid schedule is not guaranteed after this period and depends on departmental needs.
The Brigham and Women’s Hospital, Inc. 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 by law. Reasonable accommodations are provided for applicants with disabilities during the job application or interview process and to perform essential job functions.
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