Boston Medical Center (BMC)
Overview
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 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 and provider 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.
The Prior Authorization Specialist role belongs to the Revenue Cycle Patient Access team and coordinates all financial clearance activities, including pre-registration (demographic, insurance verification), obtaining referral authorizations or precertification numbers. This role ensures timely access to care while maximizing hospital reimbursement and requires adherence to quality assurance guidelines and productivity standards. This position reports to the Patient Access Supervisor and collaborates with insurance company representatives, patients, providers, and internal departments. This is a Remote Position.
Responsibilities
Prioritize incoming Prior Authorization requests.
Process incoming requests and authorize specified services per departmental policies and workflow guidelines.
Refer requests requiring clinical judgment to the Prior Authorization Clinician, Manager, or Medical Director.
Meet or exceed position metrics and turnaround times while maintaining a full caseload.
Support Prior Authorization Clinicians.
Answer ACD line calls, verify member eligibility and enter information into CCMS or Facets.
Identify and inform callers of network providers, services, and member benefits.
Explain provider decisions per department procedure.
Coordinate resolution of escalated member or provider inquiries related to Prior Authorization.
Work with members, providers and key departments to promote understanding of Prior Authorization requirements and processes.
Maintain knowledge of member handbooks and evidence of coverage.
Monitor and clear work queues for registration and prior authorization to obtain required financial clearance elements.
Comply with insurance company requirements for obtaining prior authorizations/referrals; document and facilitate financial clearance.
Navigate BMC and payer policies to obtain approvals for scheduled care; assist clinicians in understanding payer requirements.
Use databases, electronic communication, faxes, and phone calls to obtain verifications, authorizations, and referrals.
Obtain and document all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
Collaborate with practices, physicians, insurers, and patients to ensure managed care referrals and prior authorizations are recorded in practice management systems, linked to appointments/visits.
Collect information and obtain payer permissions prior to scheduled services; liaise between physicians and payers for peer-to-peer review when needed.
Escalate denied or non-blank financial clearances according to policy.
Interview patients, families, or referring physicians to obtain financial and demographic information required for reimbursement and compliance.
Maintain up-to-date demographic and insurance information in registration systems for primary, secondary, and tertiary insurances.
Review and reconcile registration and insurance information; contact patients for clarifications as needed while maintaining a customer-friendly approach.
Refer self-pay or uninsured cases to Patient Financial Counseling.
Maintain confidentiality of patient financial and medical records and comply with applicable laws and policies; report potential compliance issues.
Participate in educational offerings and adhere to organizational workflows and policies. Demonstrate customer service excellence and escalate appropriately.
Support process improvements and meet productivity and quality expectations; handle ACD calls and emails per scripting and standards.
Participate in Quality Audits and coordinate with Help Desk for IT issues and equipment service as needed.
Communicate effectively with internal and external customers and attend required trainings; assist in orienting new personnel.
Perform other related duties as assigned.
Education
High school diploma or GED required.
Associate’s Degree or higher preferred.
Experience
4-5 years of office experience in high-volume data entry, customer service call center, or health care administration.
Experience using insurance payer websites (e.g., Blue Cross Blue Shield, Medicare).
Customer service experience preferred.
Experience with insurance verification, prior authorization, pre-certification and financial clearance processes.
Knowledge, Skills & Abilities
Bilingual preferred.
Ability to process high volume of requests with 95%+ accuracy.
Ability to prioritize work and meet Turn Around Timeframes.
Effective collaboration, strong communication, and customer service skills.
Thorough knowledge of financial clearance processes; familiarity with insurance, referrals, and third-party billing.
Knowledge of medical terminology and ICD-9/CPT coding is helpful.
Strong interpersonal skills and ability to build relationships with managers, colleagues, and payers.
Self-directed, highly organized, able to multitask and work under pressure with good judgment and confidentiality.
Familiarity with Epic systems and related queues (ADT/Prelude/Grand Central) is preferred.
Proficiency with Microsoft Office (Excel, Word, Outlook) and Zoom.
Knowledge of medical terminology and coding is helpful.
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.
Additional Information
Seniority level: Entry level
Employment type: Full-time
Job function: Other
Industry: Hospitals and Health Care
Referrals increase your chances of interviewing at Boston Medical Center (BMC) by 2x. Get notified about new Specialist jobs in Boston, MA.
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The Prior Authorization Specialist role belongs to the Revenue Cycle Patient Access team and coordinates all financial clearance activities, including pre-registration (demographic, insurance verification), obtaining referral authorizations or precertification numbers. This role ensures timely access to care while maximizing hospital reimbursement and requires adherence to quality assurance guidelines and productivity standards. This position reports to the Patient Access Supervisor and collaborates with insurance company representatives, patients, providers, and internal departments. This is a Remote Position.
Responsibilities
Prioritize incoming Prior Authorization requests.
Process incoming requests and authorize specified services per departmental policies and workflow guidelines.
Refer requests requiring clinical judgment to the Prior Authorization Clinician, Manager, or Medical Director.
Meet or exceed position metrics and turnaround times while maintaining a full caseload.
Support Prior Authorization Clinicians.
Answer ACD line calls, verify member eligibility and enter information into CCMS or Facets.
Identify and inform callers of network providers, services, and member benefits.
Explain provider decisions per department procedure.
Coordinate resolution of escalated member or provider inquiries related to Prior Authorization.
Work with members, providers and key departments to promote understanding of Prior Authorization requirements and processes.
Maintain knowledge of member handbooks and evidence of coverage.
Monitor and clear work queues for registration and prior authorization to obtain required financial clearance elements.
Comply with insurance company requirements for obtaining prior authorizations/referrals; document and facilitate financial clearance.
Navigate BMC and payer policies to obtain approvals for scheduled care; assist clinicians in understanding payer requirements.
Use databases, electronic communication, faxes, and phone calls to obtain verifications, authorizations, and referrals.
Obtain and document all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
Collaborate with practices, physicians, insurers, and patients to ensure managed care referrals and prior authorizations are recorded in practice management systems, linked to appointments/visits.
Collect information and obtain payer permissions prior to scheduled services; liaise between physicians and payers for peer-to-peer review when needed.
Escalate denied or non-blank financial clearances according to policy.
Interview patients, families, or referring physicians to obtain financial and demographic information required for reimbursement and compliance.
Maintain up-to-date demographic and insurance information in registration systems for primary, secondary, and tertiary insurances.
Review and reconcile registration and insurance information; contact patients for clarifications as needed while maintaining a customer-friendly approach.
Refer self-pay or uninsured cases to Patient Financial Counseling.
Maintain confidentiality of patient financial and medical records and comply with applicable laws and policies; report potential compliance issues.
Participate in educational offerings and adhere to organizational workflows and policies. Demonstrate customer service excellence and escalate appropriately.
Support process improvements and meet productivity and quality expectations; handle ACD calls and emails per scripting and standards.
Participate in Quality Audits and coordinate with Help Desk for IT issues and equipment service as needed.
Communicate effectively with internal and external customers and attend required trainings; assist in orienting new personnel.
Perform other related duties as assigned.
Education
High school diploma or GED required.
Associate’s Degree or higher preferred.
Experience
4-5 years of office experience in high-volume data entry, customer service call center, or health care administration.
Experience using insurance payer websites (e.g., Blue Cross Blue Shield, Medicare).
Customer service experience preferred.
Experience with insurance verification, prior authorization, pre-certification and financial clearance processes.
Knowledge, Skills & Abilities
Bilingual preferred.
Ability to process high volume of requests with 95%+ accuracy.
Ability to prioritize work and meet Turn Around Timeframes.
Effective collaboration, strong communication, and customer service skills.
Thorough knowledge of financial clearance processes; familiarity with insurance, referrals, and third-party billing.
Knowledge of medical terminology and ICD-9/CPT coding is helpful.
Strong interpersonal skills and ability to build relationships with managers, colleagues, and payers.
Self-directed, highly organized, able to multitask and work under pressure with good judgment and confidentiality.
Familiarity with Epic systems and related queues (ADT/Prelude/Grand Central) is preferred.
Proficiency with Microsoft Office (Excel, Word, Outlook) and Zoom.
Knowledge of medical terminology and coding is helpful.
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.
Additional Information
Seniority level: Entry level
Employment type: Full-time
Job function: Other
Industry: Hospitals and Health Care
Referrals increase your chances of interviewing at Boston Medical Center (BMC) by 2x. Get notified about new Specialist jobs in Boston, MA.
#J-18808-Ljbffr