Boston Medical Center (BMC)
Prior Authorization Specialist I - Per Diem
Boston Medical Center (BMC), Boston, Massachusetts, us, 02298
Overview
Position Summary
Responsible for screening prior-authorization and coordination of specialized services requests in the medical care management program, including a broad range of requests for inpatient, outpatient and ancillary services. Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery. Maintains current knowledge of network resources for referral and linkage to member’s and provider’s needs. Authorizes certain specified services, under the supervision of the manager, according to departmental guidelines. Per standard workflows, forwards specified requests to the clinician for review and processing. Answers ACD line calls from providers and other departments and redirects, as needed.
Position Summary The Prior Authorization Specialist role belongs to the Revenue Cycle Patient Access team and is responsible for coordinating all financial clearance activities by navigating all pre-registration (to include acquiring or validating patient demographic, insurance, and other required elements along with insurance verification activities), obtaining referral authorization, or precertification number(s). The role ensures timely access to care while maximizing BMC hospital reimbursement. This role requires adherence to quality assurance guidelines as well as established productivity standards to support the work unit’s performance expectations. This position reports to the Patient Access Supervisor and requires interaction and collaboration with important stakeholders in the financial clearance process including but not limited to insurance company representatives, patients, physicians, Boston Medical Center (BMC) practice staff, case management and Patient Financial Counseling. This is a Remote Position.
Position : Prior Authorization Specialist I - Per Diem Department : Insurance Verification Schedule : Part Time, Per Diem
Essential Responsibilities / Duties
Prioritizes incoming Prior Authorization requests.
Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines.
Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director.
Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload.
Supports Prior Authorization Clinicians.
Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller’s request.
Identifies and informs callers of network providers, services, and available member benefits.
Informs provider of decision per department procedure.
Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.
Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes.
Maintains general understanding of applicable sections of member handbooks, and evidence of coverage.
Monitors accounts routed to registration and prior authorization work queues and clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with established management guidelines.
Maintains knowledge of and complies with insurance companies’ requirements for obtaining prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance.
Acts as subject matter expert in navigating both the BMC and payer policies to get the appropriate approvals for the scheduled care to proceed.
Uses appropriate strategies to obtain insurance verification, authorizations and referrals, including online databases, electronic correspondence, faxes, and phone calls.
Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
Works collaboratively with practices, referring physicians, insurance carriers, patients and other parties to ensure required managed care referrals and prior authorizations are obtained and recorded in practice management systems for patient appointments/visits prior to scheduled visits or retroactively if not in place at the time of the appointment/visit.
Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to scheduled services.
Liaison between physician and payer for peer to peer review when needed.
Escalates accounts that have been denied or will not be financially cleared as outlined by department policy.
Interviews patients, families or referring physicians to obtain necessary information for reimbursement and compliance.
Ensures updated demographic and insurance information is recorded in registration systems for primary, secondary and tertiary insurances.
Reviews and reconciles registration and insurance information; communicates with patients as needed and maintains customer-friendly approach.
Directs self-pay or unresolved insurance cases to Patient Financial Counseling as appropriate.
Maintains confidentiality of patient financial and medical records; adheres to regulatory confidentiality policies and advises management of potential compliance issues.
Participates in educational offerings and complies with workflows, policies and procedures; demonstrates knowledge to deliver customer experience aligned with management expectations.
Occasionally assists with process improvement and maintains productivity and quality expectations; handles ACD calls and emails following scripting and customer service standards.
Participates in quality audits and reports issues to the appropriate supervisor or IT help desk as needed.
Education and Experience
High school diploma or GED required.
Associate’s Degree or higher preferred.
4-5 years of office experience in high-volume data entry, customer service call center, or health care admin.
Experience using insurance payer websites (e.g., BCBS, Medicare).
Customer service experience preferred.
Experience with insurance verification, prior authorization, pre-certification and financial clearance process.
Knowledge, Skills & Abilities
Bilingual preferred.
Ability to process high volume with 95%+ accuracy.
Strong prioritization and turnaround time management.
Effective collaboration and communication skills.
Thorough knowledge of financial clearance; familiarity with insurances, referrals and third-party billing.
Knowledge of medical terminology; Epic experience preferred (including ADT/Prelude/Grand Centrale).
Proficiency in Microsoft Office (Excel, Word, Outlook, Zoom).
Ability to maintain confidentiality and work under pressure; good judgment and customer service orientation.
Equal Opportunity Equal Opportunity Employer/Disabled/Veterans
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.
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Position Summary The Prior Authorization Specialist role belongs to the Revenue Cycle Patient Access team and is responsible for coordinating all financial clearance activities by navigating all pre-registration (to include acquiring or validating patient demographic, insurance, and other required elements along with insurance verification activities), obtaining referral authorization, or precertification number(s). The role ensures timely access to care while maximizing BMC hospital reimbursement. This role requires adherence to quality assurance guidelines as well as established productivity standards to support the work unit’s performance expectations. This position reports to the Patient Access Supervisor and requires interaction and collaboration with important stakeholders in the financial clearance process including but not limited to insurance company representatives, patients, physicians, Boston Medical Center (BMC) practice staff, case management and Patient Financial Counseling. This is a Remote Position.
Position : Prior Authorization Specialist I - Per Diem Department : Insurance Verification Schedule : Part Time, Per Diem
Essential Responsibilities / Duties
Prioritizes incoming Prior Authorization requests.
Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines.
Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director.
Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload.
Supports Prior Authorization Clinicians.
Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller’s request.
Identifies and informs callers of network providers, services, and available member benefits.
Informs provider of decision per department procedure.
Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization.
Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes.
Maintains general understanding of applicable sections of member handbooks, and evidence of coverage.
Monitors accounts routed to registration and prior authorization work queues and clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with established management guidelines.
Maintains knowledge of and complies with insurance companies’ requirements for obtaining prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance.
Acts as subject matter expert in navigating both the BMC and payer policies to get the appropriate approvals for the scheduled care to proceed.
Uses appropriate strategies to obtain insurance verification, authorizations and referrals, including online databases, electronic correspondence, faxes, and phone calls.
Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
Works collaboratively with practices, referring physicians, insurance carriers, patients and other parties to ensure required managed care referrals and prior authorizations are obtained and recorded in practice management systems for patient appointments/visits prior to scheduled visits or retroactively if not in place at the time of the appointment/visit.
Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to scheduled services.
Liaison between physician and payer for peer to peer review when needed.
Escalates accounts that have been denied or will not be financially cleared as outlined by department policy.
Interviews patients, families or referring physicians to obtain necessary information for reimbursement and compliance.
Ensures updated demographic and insurance information is recorded in registration systems for primary, secondary and tertiary insurances.
Reviews and reconciles registration and insurance information; communicates with patients as needed and maintains customer-friendly approach.
Directs self-pay or unresolved insurance cases to Patient Financial Counseling as appropriate.
Maintains confidentiality of patient financial and medical records; adheres to regulatory confidentiality policies and advises management of potential compliance issues.
Participates in educational offerings and complies with workflows, policies and procedures; demonstrates knowledge to deliver customer experience aligned with management expectations.
Occasionally assists with process improvement and maintains productivity and quality expectations; handles ACD calls and emails following scripting and customer service standards.
Participates in quality audits and reports issues to the appropriate supervisor or IT help desk as needed.
Education and Experience
High school diploma or GED required.
Associate’s Degree or higher preferred.
4-5 years of office experience in high-volume data entry, customer service call center, or health care admin.
Experience using insurance payer websites (e.g., BCBS, Medicare).
Customer service experience preferred.
Experience with insurance verification, prior authorization, pre-certification and financial clearance process.
Knowledge, Skills & Abilities
Bilingual preferred.
Ability to process high volume with 95%+ accuracy.
Strong prioritization and turnaround time management.
Effective collaboration and communication skills.
Thorough knowledge of financial clearance; familiarity with insurances, referrals and third-party billing.
Knowledge of medical terminology; Epic experience preferred (including ADT/Prelude/Grand Centrale).
Proficiency in Microsoft Office (Excel, Word, Outlook, Zoom).
Ability to maintain confidentiality and work under pressure; good judgment and customer service orientation.
Equal Opportunity Equal Opportunity Employer/Disabled/Veterans
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.
#J-18808-Ljbffr