Mass General Brigham
Site: The Brigham and Women's Hospital, Inc.
Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Overview
The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating an exceptional patient experience by securing authorizations for all scheduled services related to medical and surgical admissions across entities, including BWH OR procedures, BWFH OR procedures, FXB OR procedures, and BWH/BWFH Endoscopy Suite procedures in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. The PAS is also responsible for securing authorizations for all Emergency and Urgent admissions to BWH and BWFH and for all Infusion Clinic Services for BWH and BWFH in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. This role contributes to the organization’s financial health, with responsibilities accounting for a significant portion of revenue per fiscal year. Qualifications
Bachelor’s degree or equivalent preferred; high school diploma required. 2+ years’ experience in hospital settings such as 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 regarding insurance reimbursement and managed care authorization and referral requirements. Technical knowledge of specific legal and regulatory requirements and an understanding of complex third-party and medical assistance policies and procedures. Knowledge of the hospital information system with emphasis on registration and insurance verification, and accounts receivables programs. Responsibilities
Maintains expert-level knowledge about the industry; utilizes it to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as aligned with organizational values and mission. Acts as subject matter expert and guide to a broad employee base, particularly providers, to educate and communicate on requirements, processes, and adjustments needed throughout the patient care journey. Interacts directly with EPIC Auth/Cert, Registration, and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, including CPT Procedure 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 agreement as needed. Uses independent judgment to make knowledgeable decisions in coordinating with physicians and offices to respond to Medical Insurance inquiries and resolve conflicts concerning approval for surgical procedures in the OR. Consults with Hospital professionals, administrative and support staff, patients, and representatives of other organizations where advanced expertise in communications is necessary to lead with tact, inclusivity, patience, and respect while maintaining confidentiality and achieving consensus with the lens of exceptional patient experience. Interacts directly with EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization (e.g., clinical notes, radiology/lab results, PT/OT notes, imaging, and photos). Different surgeries and insurers have different information needs for authorization. Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify coverage and benefits. Determines if any pre-admission requirements exist (e.g., predetermination of medical necessity, out-of-network authorization). Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State/Federal regulations; identifies contracted payers and appropriate level and type of care. Updates and verifies all data necessary to complete required registration, admission, demographic, and financial information to ensure timely access and accurate billing. Identifies incomplete clinical documentation needed for approval; collaborates with physicians/clinicians and staff via EPIC, phone, and Outlook to collect missing data. Compiles, uploads, and submits all required clinical information from Epic for preadmission approvals and precertification via Medical Insurance Payer Portals. Determines when problematic preadmissions must be referred to Sr. Manager and/or Director (e.g., legal issues, complex financial issues, special insurance exclusions). Acts as liaison between physicians, insurance companies, and Patient Financial Services across multiple campuses. Monitors pending cases to ensure approvals before admission or visit; informs offices of additional clinical requests and notes that are lacking Advises uninsured and underinsured patients regarding available programs; refers to Patient Financial Services as needed. Reviews emergency and unscreened admissions promptly to identify and minimize financial risk to the institution. Follows cases throughout admission with UR and Ontrac, maintaining payer communication for updated authorization days and addressing denials through in-house reviews. Reviews RTE eligibility in EPIC for payer changes or discrepancies and follows up for new prior authorization when payer changes mid-admission. Reviews cases for patient class changes (outpatient to inpatient) and updates authorizations accordingly; reviews Ontrac lists for exceptions and changes. Scans authorization-related information into Epic Media Manager and documents notes per QA metrics. Works with the Authorization Denials Team to prevent write-offs by researching cases and supporting possible prior auth appeals. Stays current with payer changes in authorization requirements and restrictions (e.g., new CPT codes requiring authorization, new therapies). Maintains a daily workflow of Ontrac work lists and ensures Epic auth/cert fields and notes are updated before, during, and after service until final secured status and authorization for billing. Maintains patient confidentiality and privacy, accessing information only as necessary to fulfill duties. Adheres to Customer Service Standards by demonstrating professionalism and responsiveness to patients, visitors, and staff. Interactions/Interpersonal Skills
Demonstrated excellent customer service abilities with awareness of sensitivities related to the core function and its impact on patient experience. 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. Ability to escalate to Senior Management when needed. Commitment to collaboration within a functional team to improve efficiency and achieve department goals. Strong organizational skills, multitasking ability, and problem-solving capabilities. Willingness to continuously learn and act as a trusted subject matter expert. Sound judgment, tact, sensitivity, and ability to function in a fast-paced, changing environment. Maintain confidentiality of patients and their information. Additional Job Details
The Prior Authorization Specialist position is 100% onsite at Assembly Row for the probation and training period, a minimum of 90 days. A hybrid schedule is not guaranteed after this period, based on departmental needs and performance. Remote Type
Hybrid Work Location
399 Revolution Drive Scheduled Weekly Hours
40 Employee Type
Regular Work Shift
Day (United States of America) Pay Range
$19.42 - $27.74/Hourly Grade
3 Mass General Brigham is committed to recognizing and rewarding the unique value each team member brings. Base pay reflects the minimum qualifications and may be complemented by factors including experience, education, certifications, and other elements of the total compensation package. The organization provides comprehensive benefits and opportunities for career advancement. EEO Statement
The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military status, genetic information, or other protected status. Reasonable accommodations are available upon request during the application or interview process. For accommodations, contact Human Resources at (857) 282-7642.
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The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating an exceptional patient experience by securing authorizations for all scheduled services related to medical and surgical admissions across entities, including BWH OR procedures, BWFH OR procedures, FXB OR procedures, and BWH/BWFH Endoscopy Suite procedures in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. The PAS is also responsible for securing authorizations for all Emergency and Urgent admissions to BWH and BWFH and for all Infusion Clinic Services for BWH and BWFH in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. This role contributes to the organization’s financial health, with responsibilities accounting for a significant portion of revenue per fiscal year. Qualifications
Bachelor’s degree or equivalent preferred; high school diploma required. 2+ years’ experience in hospital settings such as 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 regarding insurance reimbursement and managed care authorization and referral requirements. Technical knowledge of specific legal and regulatory requirements and an understanding of complex third-party and medical assistance policies and procedures. Knowledge of the hospital information system with emphasis on registration and insurance verification, and accounts receivables programs. Responsibilities
Maintains expert-level knowledge about the industry; utilizes it to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as aligned with organizational values and mission. Acts as subject matter expert and guide to a broad employee base, particularly providers, to educate and communicate on requirements, processes, and adjustments needed throughout the patient care journey. Interacts directly with EPIC Auth/Cert, Registration, and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, including CPT Procedure 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 agreement as needed. Uses independent judgment to make knowledgeable decisions in coordinating with physicians and offices to respond to Medical Insurance inquiries and resolve conflicts concerning approval for surgical procedures in the OR. Consults with Hospital professionals, administrative and support staff, patients, and representatives of other organizations where advanced expertise in communications is necessary to lead with tact, inclusivity, patience, and respect while maintaining confidentiality and achieving consensus with the lens of exceptional patient experience. Interacts directly with EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization (e.g., clinical notes, radiology/lab results, PT/OT notes, imaging, and photos). Different surgeries and insurers have different information needs for authorization. Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify coverage and benefits. Determines if any pre-admission requirements exist (e.g., predetermination of medical necessity, out-of-network authorization). Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State/Federal regulations; identifies contracted payers and appropriate level and type of care. Updates and verifies all data necessary to complete required registration, admission, demographic, and financial information to ensure timely access and accurate billing. Identifies incomplete clinical documentation needed for approval; collaborates with physicians/clinicians and staff via EPIC, phone, and Outlook to collect missing data. Compiles, uploads, and submits all required clinical information from Epic for preadmission approvals and precertification via Medical Insurance Payer Portals. Determines when problematic preadmissions must be referred to Sr. Manager and/or Director (e.g., legal issues, complex financial issues, special insurance exclusions). Acts as liaison between physicians, insurance companies, and Patient Financial Services across multiple campuses. Monitors pending cases to ensure approvals before admission or visit; informs offices of additional clinical requests and notes that are lacking Advises uninsured and underinsured patients regarding available programs; refers to Patient Financial Services as needed. Reviews emergency and unscreened admissions promptly to identify and minimize financial risk to the institution. Follows cases throughout admission with UR and Ontrac, maintaining payer communication for updated authorization days and addressing denials through in-house reviews. Reviews RTE eligibility in EPIC for payer changes or discrepancies and follows up for new prior authorization when payer changes mid-admission. Reviews cases for patient class changes (outpatient to inpatient) and updates authorizations accordingly; reviews Ontrac lists for exceptions and changes. Scans authorization-related information into Epic Media Manager and documents notes per QA metrics. Works with the Authorization Denials Team to prevent write-offs by researching cases and supporting possible prior auth appeals. Stays current with payer changes in authorization requirements and restrictions (e.g., new CPT codes requiring authorization, new therapies). Maintains a daily workflow of Ontrac work lists and ensures Epic auth/cert fields and notes are updated before, during, and after service until final secured status and authorization for billing. Maintains patient confidentiality and privacy, accessing information only as necessary to fulfill duties. Adheres to Customer Service Standards by demonstrating professionalism and responsiveness to patients, visitors, and staff. Interactions/Interpersonal Skills
Demonstrated excellent customer service abilities with awareness of sensitivities related to the core function and its impact on patient experience. 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. Ability to escalate to Senior Management when needed. Commitment to collaboration within a functional team to improve efficiency and achieve department goals. Strong organizational skills, multitasking ability, and problem-solving capabilities. Willingness to continuously learn and act as a trusted subject matter expert. Sound judgment, tact, sensitivity, and ability to function in a fast-paced, changing environment. Maintain confidentiality of patients and their information. Additional Job Details
The Prior Authorization Specialist position is 100% onsite at Assembly Row for the probation and training period, a minimum of 90 days. A hybrid schedule is not guaranteed after this period, based on departmental needs and performance. Remote Type
Hybrid Work Location
399 Revolution Drive Scheduled Weekly Hours
40 Employee Type
Regular Work Shift
Day (United States of America) Pay Range
$19.42 - $27.74/Hourly Grade
3 Mass General Brigham is committed to recognizing and rewarding the unique value each team member brings. Base pay reflects the minimum qualifications and may be complemented by factors including experience, education, certifications, and other elements of the total compensation package. The organization provides comprehensive benefits and opportunities for career advancement. EEO Statement
The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military status, genetic information, or other protected status. Reasonable accommodations are available upon request during the application or interview process. For accommodations, contact Human Resources at (857) 282-7642.
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