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Role Description

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, obtaining referral authorization, or precertification number(s). 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
• Patient Financial Counseling

This is a Remote Position.

Qualifications

• High school diploma or GED required.
• Associate’s Degree or higher preferred.
• 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.
• 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.

Requirements

• 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.
• 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.

Benefits

• Compensation Range: $25.42- $30.97.
• Generous total compensation that includes benefits (medical, dental, vision, pharmacy).
• Contract increases.
• Flexible Spending Accounts.
• 403(b) savings matches.
• Earned time cash out.
• Paid time off.
• Career advancement opportunities.
• Resources to support employee and family wellbeing.

Company Description

Equal Opportunity Employer/Disabled/Veterans.

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