Prior Authorization Specialist

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.

This position completes all financial clearance activities for services rendered in outpatient departments. Monitors outcomes to ensure medical necessity and authorization requirements are met. Provides feedback to departments on medical necessity and authorization processes.

Job Description:

Primary Responsibilities:

1. Verifies patient's insurance eligibility for visit, using various online tools and by contacting the payer directly. (essential)

2. Identifies payer medical necessity determination before services are rendered. Informs departments of failed instances. When circumstances dictate, requests additional information to re-run medical necessity check. (essential)

3. Determines authorization requirement and, when necessary, obtains authorization from payer by utilizing payer specific protocols. Requests and coordinates any additional information from departments when needed. (essential)

4. Identifies and escalates issues timely and appropriately for resolution and communicates and coordinates with revenue cycle peers, leadership and clinical stakeholders. Documents interim and final results in appropriate systems. (essential)

5. Completes assigned work queues and reports daily to achieve standards of productivity and quality. Assists with reviewing medical necessity and obtaining authorization for urgent or walk-in visits. Refers patients to financial counselors to resolve complex financial issues and/or inquiries. (essential)

6. Follows BIDMC policies, procedures and training materials to ensure compliance to federal, state, and contractual requirements. (essential)

7. Identifies trends and provides periodic reports to departments on operational, productivity, and quality metrics. (essential)

8. Performs other activities on an as-needed basis to support the department. (essential)

Required Qualifications:

1. High School diploma or GED required. Associate's degree preferred.

2. 1-3 years related work experience required.

3. Working knowledge of Common Procedural Terminology (CPT), Health Care Procedural Coding System (HCPCS) coding and International Classification of Diseases (ICD-9, ICD-10).

4. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.

Preferred Qualifications:

1. 3+ years of related experience; two or more years of prior work experience in Financial Clearance activities.

2. Knowledge of payer policies for medical necessity/authorization requirements.

3. Prior experience working with Craneware software.

Competencies:

Decision Making: Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.

Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.

Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.

Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.

Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.

Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.

Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.

Social/Environmental Requirements:

1. Work requires close attention to task for work to be accurately completed. Intermittent breaks during the work day do not compromise the work.

2. Work is varied every day and the employee needs to be adaptable to respond to these changes and use independent judgment and manage priorities.

3. No substantial exposure to adverse environmental conditions

4. Health Care Status: NHCW: No patient contact.- Health Care Worker Status may vary by department

Sensory Requirements:

Close work (paperwork, visual examination), Color vision/perception, Visual monotony, Visual clarity <3 feet, Conversation, Telephone.

Physical Requirements:

Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally

This job requires constant sitting, Keyboard use.There may be occasional Fin

Pay Range:
$20.50 - $27.59

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