Beacon Health System
Overview
Join to apply for the
Prior-Authorization Spec (BMG)
role at
Beacon Health System . Responsibilities
Reports to the VP Patient Access. Responsibilities include evaluating designated referred services for authorization needs based on government and commercial payor requirements. Disseminating all clinical and coding supporting documentation to effectively complete the authorization process to ensure appropriate reimbursement. In addition, this position provides exceptional customer service during every encounter with patients, families, visitors and BMG associates by communicating with empathy and clarity regarding the details of the next step in care for the customer. Serving as primary contact and resource for all designated prior authorization needs. Identifying, collecting, and coordinating clinical documentation to support the qualification of ordered services. Evaluating orders for insurance coverage and authorization requirements. Ensuring carrier process requirements are met within contracted guidelines and timeliness. Ensuring proper testing is done using tools in accordance with the provider's preferences and testing criteria and guidelines, including both insurance and modality ordering. Reviewing and complying with additional requests. Validating completed authorizations to ensure the authorization corresponds with the ordered service, code, time frame and provider. Supporting the appeal process by communicating and coordinating resolution expectations with the provider and authorization agent. Maintaining standardized records to allow for effective coordinating, tracking and reporting of department actions and metrics. Advocating for the customer by recognizing when to dispute an unfavorable outcome regarding PA (prior authorization). Disputing and negotiating, when necessary, on behalf of Beacon Health System and the customer for a positive prior authorization outcome. Providing exceptional customer-centric service during every encounter with patients, families, and associates. Using critical thinking skills to make decisions, identify problems, create solutions and help implement change; escalate concerns when necessary. Participating in performance improvement by following established work systems, identifying deviations or deficiencies in standards/systems/processes and communicating problems to the supervisor or manager. Prioritizing work effectively. Working at a fast pace and maintaining accuracy. Understanding the flow and rhythm of each task and how it contributes to connected, coordinated care. Using multiple software platforms (multiple EMRs, insurance websites, referral databases, scheduling software, etc.) to conduct tasks for patient care. Performs other functions
Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by: Assisting others and/or accepting additional duties. Enhancing professional growth and development through in-service meetings and educational programs as approved. Maintaining up-to-date knowledge and staying abreast of changes and updates as they occur (including insurance, department and process changes). Organizational Responsibilities
Associate complies with the following organizational requirements: Attends and participates in department meetings and is accountable for all information shared. Completes mandatory education, annual competencies and department-specific education within established timeframes. Completes annual employee health requirements within established timeframes. Maintains license/certification, registration in good standing throughout the fiscal year. Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department. Consistently utilizes universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Adheres to regulatory agency requirements, survey process and compliance. Complies with established organization and department policies. Available to work overtime and to work additional or different shifts and schedules when required. Beacon Way
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way: Leverage innovation everywhere. Cultivate human talent. Embrace performance improvement. Build greatness through accountability. Use information to improve and advance. Communicate clearly and continuously. Education And Experience
The knowledge, skills and abilities as indicated are normally acquired through the successful completion of an Associate's Degree in a Business or Health Care related field and one year of medical authorization or related experience; or, in lieu of a degree, completion of a high school diploma or equivalent and three years medical authorization or related experience. Successful completion of an approved Medical Assistant Program with successful completion of the Certification Exam or equivalent medical office experience is preferred. Medical terminology, ICD-10, CPT, prior authorizations, third party payors and prior authorization processes is required. Working knowledge of Microsoft Office: Outlook, Excel and Word. Knowledge & Skills
Demonstrates well-developed communication skills to communicate effectively and clearly to a variety of internal and external contacts. Demonstrates analytical skills necessary to solve problems and interpret data. Promotes collaboration and innovation in clinical services to ensure an interdisciplinary approach to improving healthcare delivery and the quality of patient care. Must be tactful in handling patient problems often of a highly personal and confidential nature. Maintains professionalism during potentially frustrating interpersonal situations. Demonstrates knowledge of CPT codes and ICD-10 Codes. Has working knowledge of insurance network guidelines to ensure referrals are scheduled in accordance with customers insurance rules and regulations; demonstrates understanding of payor requirements to navigate the authorization process via website, fax or phone. Possesses analytical skills to apply knowledge and evaluate clinical information to resolve denials through various levels of appeal. Working knowledge of Microsoft Office: Outlook, Excel and Word. Possesses strong customer service, communication, organizational and analytical skills. Working Conditions
Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs. May need to travel to other Beacon locations and may be required to work evening hours. Working space is frequently congested by other personnel. Constantly exposed to noise and distraction. Physical Demands
Requires the physical ability and stamina to perform the essential functions of the position. Sitting for long periods of time in front of a computer monitor. Seniority level
Entry level Employment type
Full-time Job function
Other Industries
Hospitals and Health Care
#J-18808-Ljbffr
Join to apply for the
Prior-Authorization Spec (BMG)
role at
Beacon Health System . Responsibilities
Reports to the VP Patient Access. Responsibilities include evaluating designated referred services for authorization needs based on government and commercial payor requirements. Disseminating all clinical and coding supporting documentation to effectively complete the authorization process to ensure appropriate reimbursement. In addition, this position provides exceptional customer service during every encounter with patients, families, visitors and BMG associates by communicating with empathy and clarity regarding the details of the next step in care for the customer. Serving as primary contact and resource for all designated prior authorization needs. Identifying, collecting, and coordinating clinical documentation to support the qualification of ordered services. Evaluating orders for insurance coverage and authorization requirements. Ensuring carrier process requirements are met within contracted guidelines and timeliness. Ensuring proper testing is done using tools in accordance with the provider's preferences and testing criteria and guidelines, including both insurance and modality ordering. Reviewing and complying with additional requests. Validating completed authorizations to ensure the authorization corresponds with the ordered service, code, time frame and provider. Supporting the appeal process by communicating and coordinating resolution expectations with the provider and authorization agent. Maintaining standardized records to allow for effective coordinating, tracking and reporting of department actions and metrics. Advocating for the customer by recognizing when to dispute an unfavorable outcome regarding PA (prior authorization). Disputing and negotiating, when necessary, on behalf of Beacon Health System and the customer for a positive prior authorization outcome. Providing exceptional customer-centric service during every encounter with patients, families, and associates. Using critical thinking skills to make decisions, identify problems, create solutions and help implement change; escalate concerns when necessary. Participating in performance improvement by following established work systems, identifying deviations or deficiencies in standards/systems/processes and communicating problems to the supervisor or manager. Prioritizing work effectively. Working at a fast pace and maintaining accuracy. Understanding the flow and rhythm of each task and how it contributes to connected, coordinated care. Using multiple software platforms (multiple EMRs, insurance websites, referral databases, scheduling software, etc.) to conduct tasks for patient care. Performs other functions
Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by: Assisting others and/or accepting additional duties. Enhancing professional growth and development through in-service meetings and educational programs as approved. Maintaining up-to-date knowledge and staying abreast of changes and updates as they occur (including insurance, department and process changes). Organizational Responsibilities
Associate complies with the following organizational requirements: Attends and participates in department meetings and is accountable for all information shared. Completes mandatory education, annual competencies and department-specific education within established timeframes. Completes annual employee health requirements within established timeframes. Maintains license/certification, registration in good standing throughout the fiscal year. Direct patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department. Consistently utilizes universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Adheres to regulatory agency requirements, survey process and compliance. Complies with established organization and department policies. Available to work overtime and to work additional or different shifts and schedules when required. Beacon Way
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way: Leverage innovation everywhere. Cultivate human talent. Embrace performance improvement. Build greatness through accountability. Use information to improve and advance. Communicate clearly and continuously. Education And Experience
The knowledge, skills and abilities as indicated are normally acquired through the successful completion of an Associate's Degree in a Business or Health Care related field and one year of medical authorization or related experience; or, in lieu of a degree, completion of a high school diploma or equivalent and three years medical authorization or related experience. Successful completion of an approved Medical Assistant Program with successful completion of the Certification Exam or equivalent medical office experience is preferred. Medical terminology, ICD-10, CPT, prior authorizations, third party payors and prior authorization processes is required. Working knowledge of Microsoft Office: Outlook, Excel and Word. Knowledge & Skills
Demonstrates well-developed communication skills to communicate effectively and clearly to a variety of internal and external contacts. Demonstrates analytical skills necessary to solve problems and interpret data. Promotes collaboration and innovation in clinical services to ensure an interdisciplinary approach to improving healthcare delivery and the quality of patient care. Must be tactful in handling patient problems often of a highly personal and confidential nature. Maintains professionalism during potentially frustrating interpersonal situations. Demonstrates knowledge of CPT codes and ICD-10 Codes. Has working knowledge of insurance network guidelines to ensure referrals are scheduled in accordance with customers insurance rules and regulations; demonstrates understanding of payor requirements to navigate the authorization process via website, fax or phone. Possesses analytical skills to apply knowledge and evaluate clinical information to resolve denials through various levels of appeal. Working knowledge of Microsoft Office: Outlook, Excel and Word. Possesses strong customer service, communication, organizational and analytical skills. Working Conditions
Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs. May need to travel to other Beacon locations and may be required to work evening hours. Working space is frequently congested by other personnel. Constantly exposed to noise and distraction. Physical Demands
Requires the physical ability and stamina to perform the essential functions of the position. Sitting for long periods of time in front of a computer monitor. Seniority level
Entry level Employment type
Full-time Job function
Other Industries
Hospitals and Health Care
#J-18808-Ljbffr