Prior Authorization Specialist I

Position: Prior Authorization Specialist I    Department: Patient Access Services   Schedule: Full Time; 40-hours/week POSITION SUMMARY: This position can support Boston Medical Center Heath System departments at BMC, Good Samaritan, and St Elizabeth’s Hospitals. This position works out of Epic, and various payor portals to verify patient’s insurance and obtain authorizations. 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. JOB REQUIREMENTS EDUCATION : High school diploma or GED required. Associate’s Degree or higher preferred. CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED : None. EXPERIENCE : 4-5 years of office experience, specifically in either a high volume data entry office, customer service call center or health care office or hospital administration is required. Meditech experience is strongly preferred Experience using Insurance payer websites   (i.e. Blue Cross Blue Shield, Medicare, etc.) Customer service experience preferred. Experience with insurance verification, prior authorization, pre-certification and financial clearance process.   ​ KNOWLEDGE, SKILLS & ABILITIES (KSAs) : Bilingual preferred Ability to process high volume of requests with a 95% or greater accuracy rate Ability to prioritize work load when processing referrals and authorization requests per guidelines and within specified Turn Around Timeframes Effective collaboration skills Strong oral and written communication skills Thorough knowledge of financial clearance process is a must. Familiarity with insurances, referral authorizations and third party billing procedures. Knowledge of basic medical terminology and ICD-9/CPT coding is helpful. Excellent interpersonal skills to build and maintain strong relationships with managers, colleagues, and third party payers. Must be self-directed and highly organized with the ability to multitask, manage complex processes, and maintain fair sense of urgency. Requires ability to make independent decisions under pressure. Requires excellent judgment, diplomacy, collaboration, partnering, teamwork, and customer service skills. Ability to maintain confidentiality of all personal/health sensitive information. Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail. Knowledge of and experience within Epic is preferred. Demonstrates technical proficiency within assigned Epic work queues and applicable ancillary systems, including but not limited to: ADT/Prelude/Grand Centrale. Must be able to maintain strict confidentiality of all personal/health sensitive information. Basic computer proficiency inclusive of ability to access, enter and interpret computerized data/information including proficiency in Microsoft Suite applications, specifically Excel, Word, Outlook and Zoom. Knowledge of medical terminology and/ or coding. ESSENTIAL RESPONSIBILITIES / DUTIES: Prioritizes incoming Prior Authorization requests. Processes incoming requests, including authorizing specified services, as outlined in departmental policies, procedures, and workflow guidelines. Refers authorization requests that require clinical judgment to Prior Authorization Clinician, Manager, or Medical Director. Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload. Supports Prior Authorization Clinicians. Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller’s request. Identifies and informs callers of network providers, services, and available member benefits. Informs provider of decision per department procedure. Coordinates resolution of escalated member or provider inquiries as related to Prior Authorization. Works with members, providers and key departments to promote an understanding of Prior Authorization requirements and processes. Maintains general understanding of applicable sections of member handbooks, and evidence of coverage. Monitors accounts routed to registration and prior authorization work queues and clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with establishe