Beacon Health System
Overview
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.
Mission, Values, and Service Goals
MISSION:
We deliver outstanding care, inspire health, and connect with heart.
VALUES:
Trust. Respect. Integrity. Compassion.
SERVICE GOALS:
Personally connect. Keep everyone informed. Be on their team.
Prior Authorization Specialist Duties
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 and utilizing tools in accordance with the provider's desire and the testing criteria and guidelines including both insurance and modality ordering guidelines.
Reviewing and complying with additional requests.
Validating completed authorizations to ensure the authorization corresponds with ordered service, code, time frame and provider.
Supporting the appeal process by communicating and coordinating resolution expectations with 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 a non‑desirable outcome regarding PA approval.
Disputing and negotiating, when necessary, on behalf of BHS 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.
Escalating concerns when necessary.
Participating in performance improvement activities.
Prioritizing work effectively.
Working at a fast pace while maintaining accuracy.
Understanding the flow and rhythm of each task and connecting each resulting care.
Using multiple software platforms (multiple EMRs, insurance websites, referral database, scheduling software, etc.) to conduct tasks for patient care.
Other Functions
Assisting others and/or accepting additional duties.
Enhancing professional growth and development through in‑service meetings and educational programs.
Maintaining up‑to‑date knowledge of changes and updates as they occur.
Organizational Responsibilities
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 fiscal year.
Direct patient care providers required to maintain current BCLS (CPR) and other certifications as required by position/department.
Consistently utilizes appropriate 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 additional shifts when required.
Commitment to Beacon's Six‑Point Operating System
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
Associate's Degree in Business or Health Care related field and one year medical authorization or related experience; or high school diploma or equivalent and three years medical authorization or related experience. Preferred: completion of an approved Medical Assistant Program with certification exam or equivalent medical office experience. Knowledge of 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
Well‑developed communication skills for clear interaction with internal and external contacts.
Analytical skills to solve problems and interpret data.
Promotes collaboration and innovation in clinical services to ensure interdisciplinary improvement of patient care quality.
Tactful in handling sensitive patient issues.
Professional conduct in potentially frustrating situations.
High knowledge of CPT and ICD‑10 codes.
Strong knowledge of insurance network guidelines to schedule referrals in accordance with customer insurances rules and regulations.
High understanding of payor requirements to navigate authorization via website, fax or phone.
Continual knowledge of insurance updates.
Analytical skills to evaluate clinical information and resolve denials through appeals.
Proficient in Microsoft Office: Outlook, Excel and Word.
Strong customer service, communication, organizational, and analytical skills.
Working Conditions
Assigned hours and shifts may change based on departmental needs.
May need to travel to other Beacon locations and work evening hours.
Work space often congested by other personnel.
Constant exposure to noise and distraction.
Physical Demands
Requires physical ability and stamina for essential functions.
Sitting for long periods in front of a computer monitor.
Seniority Level Entry level
Employment type Full‑time
Job Function Other
Industries Hospitals and Health Care
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Mission, Values, and Service Goals
MISSION:
We deliver outstanding care, inspire health, and connect with heart.
VALUES:
Trust. Respect. Integrity. Compassion.
SERVICE GOALS:
Personally connect. Keep everyone informed. Be on their team.
Prior Authorization Specialist Duties
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 and utilizing tools in accordance with the provider's desire and the testing criteria and guidelines including both insurance and modality ordering guidelines.
Reviewing and complying with additional requests.
Validating completed authorizations to ensure the authorization corresponds with ordered service, code, time frame and provider.
Supporting the appeal process by communicating and coordinating resolution expectations with 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 a non‑desirable outcome regarding PA approval.
Disputing and negotiating, when necessary, on behalf of BHS 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.
Escalating concerns when necessary.
Participating in performance improvement activities.
Prioritizing work effectively.
Working at a fast pace while maintaining accuracy.
Understanding the flow and rhythm of each task and connecting each resulting care.
Using multiple software platforms (multiple EMRs, insurance websites, referral database, scheduling software, etc.) to conduct tasks for patient care.
Other Functions
Assisting others and/or accepting additional duties.
Enhancing professional growth and development through in‑service meetings and educational programs.
Maintaining up‑to‑date knowledge of changes and updates as they occur.
Organizational Responsibilities
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 fiscal year.
Direct patient care providers required to maintain current BCLS (CPR) and other certifications as required by position/department.
Consistently utilizes appropriate 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 additional shifts when required.
Commitment to Beacon's Six‑Point Operating System
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
Associate's Degree in Business or Health Care related field and one year medical authorization or related experience; or high school diploma or equivalent and three years medical authorization or related experience. Preferred: completion of an approved Medical Assistant Program with certification exam or equivalent medical office experience. Knowledge of 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
Well‑developed communication skills for clear interaction with internal and external contacts.
Analytical skills to solve problems and interpret data.
Promotes collaboration and innovation in clinical services to ensure interdisciplinary improvement of patient care quality.
Tactful in handling sensitive patient issues.
Professional conduct in potentially frustrating situations.
High knowledge of CPT and ICD‑10 codes.
Strong knowledge of insurance network guidelines to schedule referrals in accordance with customer insurances rules and regulations.
High understanding of payor requirements to navigate authorization via website, fax or phone.
Continual knowledge of insurance updates.
Analytical skills to evaluate clinical information and resolve denials through appeals.
Proficient in Microsoft Office: Outlook, Excel and Word.
Strong customer service, communication, organizational, and analytical skills.
Working Conditions
Assigned hours and shifts may change based on departmental needs.
May need to travel to other Beacon locations and work evening hours.
Work space often congested by other personnel.
Constant exposure to noise and distraction.
Physical Demands
Requires physical ability and stamina for essential functions.
Sitting for long periods in front of a computer monitor.
Seniority Level Entry level
Employment type Full‑time
Job Function Other
Industries Hospitals and Health Care
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