Prior Authorization Specialist
Healthcare
PriorAuthorizationSpecialist
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Prior Authorization Specialist at Prior Authorization Specialist. Skills: Prior Authorization, Financial Clearance, Insurance Verification. Screen prior-authorization requests. Coordinate specialized services requests”
What You'll Achieve.
Meet or exceed position metrics; Meet Turn-Around Timeframes; Maintain full caseload
Industry & Context.
Independent decision making; Judgment; Problem solving
Maintain confidentiality of sensitive information
What They're Looking For.
Must Have
Process high volume requests with 95% accuracy, Prioritize work load per guidelines, Meet Turn-Around Timeframes, Maintain full caseload, Thorough knowledge of financial clearance process, Familiarity with insurances, Familiarity with referral authorizations, Familiarity with third party billing procedures, Basic computer proficiency, Proficiency in Microsoft Suite, Proficiency in Excel, Proficiency in Word, Proficiency in Outlook, Proficiency in Zoom, Maintain strict confidentiality
Nice to Have
Bilingual preferred, Knowledge of basic medical terminology, Knowledge of ICD-9/CPT coding, Experience within Epic preferred, Knowledge of medical terminology, Knowledge of coding
What You'll Do.
Screen prior-authorization requests
Coordinate specialized services requests
Adhere to policies and procedures
Maintain knowledge of network resources
Authorize specified services
Forward requests to clinician
Answer ACD line calls
Coordinate financial clearance activities
Acquire patient demographic information
Validate patient demographic information
Acquire insurance information
Validate insurance information
Obtain referral authorization
Obtain precertification number
Ensure timely access to care
Maximize hospital reimbursement
Adhere to quality assurance guidelines
Support productivity standards
Prioritize incoming Prior Authorization requests
Process incoming requests
Refer authorization requests to clinician
Support Prior Authorization Clinicians
Verify member eligibility
Enter information into CCMS
Enter information into Facets
Identify network providers
Inform callers of services
Inform callers of member benefits
Inform provider of decision
Coordinate resolution of escalated inquiries
Promote understanding of requirements
Promote understanding of processes
Maintain understanding of member handbooks
Maintain understanding of evidence of coverage
Monitor registration work queues
Monitor prior authorization work queues
Obtain patient financial clearance elements
Obtain payer-specific financial clearance elements
Comply with insurance companies' requirements
Complete activities to facilitate financial clearance
Navigate BMC policies
Navigate payer policies
Obtain appropriate approvals
Obtain authorizations
Help clinicians understand payer requirements
Use appropriate strategies for insurance verification
Use appropriate strategies for authorizations
Use appropriate strategies for referrals
Obtain referral prior authorizations
Document referral prior authorizations
Obtain managed care referrals
Obtain prior authorizations for specialty visits
Record prior authorizations
Ensure approval numbers are linked
Obtain necessary information
Obtain payer permissions
Liaise between physician and payer
Escalate denied accounts
Escalate accounts not financially cleared
Interview patients via telephone
Interview families via telephone
Interview referring physicians via telephone
Obtain financial information
Obtain demographic information
Ensure updated demographic information is recorded
Ensure updated insurance information is recorded
Reconcile registration information
Reconcile insurance information
How You'll Work.
Team & Collaboration
Interact with stakeholders; Collaborate with insurance company representatives; Collaborate with patients; Collaborate with physicians; Collaborate with BMC practice staff; Collaborate with case management; Collaborate with Patient Financial Counseling; Collaborate with primary care practices; Collaborate with specialty practices; Collaborate with referring physicians; Collaborate with primary care physicians; Collaborate with insurance carriers; Collaborate with other departments; Collaborate with managers; Collaborate with colleagues; Collaborate with third party payers
Communication Scope
Oral communication; Written communication
Full Job Description
**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. 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 **Department** : Insurance Verification **Schedule** : Part Time (8:30A-3P) **ESSENTIAL RESPONSIBILITIES & DUTIES**: * Prioriti
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