Sr Prior Authorization Specialist - Winchester Hospital

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. **Hybrid role** Contribute to the Hospital’s mission by ensuring that all information necessary for proper financial reimbursement for high dollar patient care is analyzed and submitted to insurance companies for approval prior to the patient’s date of service. Collaborate with insurance companies when necessary to proactively validate benefits, eligibility and referral requirements. Communicates with patients to assure they understand their payment obligations and steps necessary to meet these obligations, while maintaining a positive patient experience. Job Description: Consistent with the PROMISE principles and inherent in a hospital environment, employees must be flexible in meeting patients’ and the Hospital’s needs. While the list below describes the primary functions of this job, all employees at Winchester Hospital need to recognize that an essential element of their job is the ability to respond to unanticipated and/or changing situations. This may result in assuming responsibilities or tasks, which are not on this list. As part of the Patient Access team, this position: Accesses work queues and reports and reviews patient accounts to determine financial clearance status of specific patient services. Takes action on those services without financial clearance. Ensures demographic and patient contact information is complete and verified with the patient or patient representative. Verifies the guarantor type and information and ensures it is assigned to the account correctly. This includes personal/family relations, workers compensation insurance, third parties, behavioral health or others as required. Ensures all possible coverages are created and verified, through electronic or manual methods, and all discrepancies are resolved. Validates that coverages are assigned to appropriate visit. Collects and validates visit-related registration information including MSPQ, occurrence codes, and attending and referring providers. Verifies Primary Care Physician (PCP) information and ensures appropriate PCP referrals are in place for the provider and service by checking electronic systems and calling PCP offices. Enters and links referrals in system. Processes referrals when necessary, assuring proper tracking and redirection when appropriate. Understands each clinical department’s referral certification protocols and ensure referrals are certified at the appropriate level. Using system activities and functions, identifies non-covered services and prepares proper Advance Notice Beneficiary (ABN) or waiver for registration team. Documents account for registrar action. Analyzed clinical documentation in support of ordered procedure(s) and submits precertification requests through various insurance fax line, phone systems and web portals. Follow up on pending accounts and involves ordering provider offices as needed to obtain approvals. Escalates challenging accounts to provider representative to ensure accounts are approved at least two weeks prior to patient appointment/surgery. Collaborates with clinical departments to facilitate scheduling of approved procedures and rescheduling of no-urgent non-certified cases. Professionally communicates outcome to patient when needed. Escalates non-certified urgent cases to appropriate clinical departments and leadership for approval to proceed or rescheduling. Verifies covered benefits, including remaining hospital days, carve out coverages and benefit limits of visit and/or timeframe. Contacts patients, providers and insurance companies to validate data, collect missing information and resolve information discrepancies, Understands clinical guidelines for payors requiring authorization to better build cases for authorization requests and provide feedback to clinical departments on required notes. Communicates with patients and discusses their financial clearance status when necessary. Explains the status of any services not financially cleared and advises patients of the proper resolution steps, including self-payment. Directs patients to Lahey Financial Counselors when appropriate. Works with the Financial Counselors, clinical departments, outside providers, third party insurers and any other individual or entity to assist in resolving patient financial clearance questions or problems in the most effective and positive manner possible. Researches claim edits and payment denials related to financial clearance and works closely with the Lahey Patient Financial Services staff to resolve these denials. Communicates resolution to patients. Qualifications: Education: High School Diploma or equivalent Experience: At least two years prior experience in a business/health care setting required. Knowledge of insurance coverage and/or reimbursement required. Experience providing customer service, while processing and verifying electronic demographic, financial or other business-related information and data. Other Skills/Knowledge: Able to work successfully in a fast-paced, multi-task environment, where some independent decision making is necessary. Able to process electronic information and data accurately and efficiently. For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors and fellow members of the hospital team. Pay Range: $21.53 - $28.98 The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law. As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger. Equal Opportunity Employer/Veterans/Disabled At Beth Israel Lahey Health, we are driving the change in health care that Massachusetts wants and needs. Our culture promotes continuous learning, growth, innovation and a sense of belonging. We make it a priority to offer comprehensive compensation and benefits and help you achieve a healthy and balanced life. While you're busy caring for and supporting our patients, we take care of you.