Prior Authorization Specialist

Site: Mass General Brigham Incorporated

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary
Summary:

-Reviews and processes prior authorization and referral requests for medical services in accordance with organizational policies and payer requirements. Ensures insurance eligibility, coordination of benefits, site-of-care compliance, and medical necessity by gathering and submitting complete medical documentation in alignment with HIPAA standards. Accurately documents authorization outcomes and all payer communications in the electronic health record.

Does this position require Patient Care? No

-Essential Functions:
-Work as part of a group to secure insurance authorizations in an appropriate timeframe. Collects and accurately enters information required by third parties for precertification for procedures, tests and imaging.
-When unclear, collaborates with ordering clinicians to ensure the proper CPT codes are submitted for prior authorization or referrals.
-Refer patients to financial counseling, as appropriate.
-Inform patient of authorization concerns prior to admission/procedure, coordinating with appropriate parties to facilitate authorization as appropriate, collaborating with other departments/offices to resolve complex authorization issues.
-Update authorization status in system and complete workflow.
-Respond to internal and external inquiries regarding authorization decisions and provide explanations as needed.

Qualifications

Education
High School Diploma or Equivalent required

Can this role accept experience in lieu of a degree?
No

Licenses and Credentials

Medical authorization or related field experience 1-2 years preferred and Epic experience 0-1 year preferred

Knowledge, Skills and Abilities
- Excellent attention to detail and organizational skills.
- Strong communication and interpersonal skills.
- Knowledge of medical terminology and medical insurance benefits, including a complete understanding of the coordination of benefits.
- Familiarity with computer systems and databases.
- Ability to work independently and as part of a team.
- Ability to work in a fast-paced environment.

Additional Job Details (if applicable)

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range
$ - $28.30/Hourly

Grade
3

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

0100 Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at View phone number on click.appcast.io.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.