Prior Authorization Specialist I

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 I Department : Insurance Verification Schedule : Full Time (Remote, 8:30AM - 5:30PM) 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. 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 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 established management guidelines. Maintains knowledge of and complies with insurance companies' requirements for obtaining prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance. Acts as subject matter expert in navigating both the BMC and payer policies to get the appropriate approvals for the scheduled care to proceed. Uses appropriate strategies to streamline the process of obtaining insurance verification, authorizations and referrals, including online databases, electronic correspondence, faxes, and phone calls. Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment. Works collaboratively with primary care practices, specialty practices, referring physicians, insurance carriers, patients and any other parties to ensure that required managed‑care referrals and prior authorizations for specific specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems. Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients' scheduled services. Liaises between physician and payer for peer‑to‑peer review when needed. Escalates accounts that have been denied or will not be financially cleared as outlined by department policy. Interviews patients, families, or referring physicians via telephone in advance of the patient's appointment/visit whenever possible, to obtain all necessary financial and demographic information required for reimbursement and compliance. Ensures that all updated demographic and insurance information is accurately recorded in the appropriate registration systems. Reviews all registration and insurance information in systems and reconciles with information available from insurance carriers. For any insurance updates, utilizes available resources to validate coverage, eligibility, and other details. For self‑pay patients or patients with unresolved insurance, refers patients to Patient Financial Counseling. Maintains confidentiality of patient's financial and medical records; adheres to state and federal laws regulating collection in healthcare; follows enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately. Participates in educational offerings sponsored by BMC or other development opportunities as available and complies with all applicable organizational workflows. Demonstrates knowledge and skills necessary to provide a high level of customer experience aligned with BMC management expectations. Recognizes situations that require escalation to the Supervisor. Takes opportunity to learn other roles and processes and assists with process improvement initiatives. Consistently meets productivity and quality expectations to align performance with assigned roles and responsibilities. Handles ACD telephone calls and emails in a timely fashion, following applicable scripting and customer service standards. Undergoes quality audits to achieve the required standard. Contacts the Help Desk in the BMC Information Technology Department to report faulty systems or hardware and notifies the supervisor if unresolved. Communicates with all internal and external customers effectively and courteously. Attends all necessary hospital and department training as required. Assists in the orientation of new personnel under direction of a manager or Supervisor. Performs other related duties as assigned or required. Must adhere to all of BMC's RESPECT behavioral standards. JOB REQUIREMENTS EDUCATION High school diploma or GED required. Associate's Degree or higher preferred. EXPERIENCE 4-5 years of office experience, specifically in a high‑volume data entry office, customer service call center, healthcare office or hospital administration. Experience using insurance payer websites (e.g. Blue Cross Blue Shield, Medicare). Customer service experience preferred. Experience with insurance verification, prior authorization, pre‑certification and financial clearance process. 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 within specified Turn‑around Timeframes. Strong oral and written communication skills. Thorough knowledge of financial clearance process; 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 relationships with managers, colleagues, and third‑party payers. Self‑directed and highly organized with the ability to multitask, manage complex processes, and maintain sense of urgency. Ability to make independent decisions under pressure. Excellent judgment, diplomacy, collaboration, partnering, teamwork, and customer service skills. Ability to maintain confidentiality of all personal/health sensitive information. Comfortable with ambiguity; good decision making, judgment and attention to detail. Knowledge of and experience within Epic is preferred. Technical proficiency within assigned Epic work queues and ancillary systems (ADT/Prelude/Grand Centrale). Basic computer proficiency, including ability to access, enter and interpret computerized data, and proficiency in Microsoft Suite applications (Excel, Word, Outlook, Zoom). Knowledge of medical terminology and/or coding. COMPENSATION RANGE $25.42 - $30.97 per hour Equal Opportunity Employer/Disabled/Veterans. According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require download of any applications, and we do not offer job openings over text messages or social media platforms. 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