Prior Authorization Specialist
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Job Description
Remote Prior Authorization Specialist coordinating insurance verification, referrals, and authorizations for Boston Medical Center patients. Supporting timely access to care and hospital reimbursement.
Responsibilities:
- Screen and prioritize incoming prior-authorization and specialized-services requests
- Process authorization requests and authorize specified services under departmental guidelines
- Refer requests requiring clinical judgment to the Prior Authorization Clinician, Manager, or Medical Director
- Meet position metrics and turnaround timeframes while maintaining a full caseload
- Support Prior Authorization Clinicians
- Answer ACD calls, verify member eligibility, and enter information into CCMS or Facets
- Identify and explain network providers, services, and member benefits
- Inform providers of authorization decisions
- Coordinate resolution of escalated member and provider inquiries
- Monitor registration and prior-authorization work queues and obtain financial-clearance elements
- Obtain and document referrals and prior authorizations in Epic
- Coordinate with practices, physicians, insurance carriers, patients, and departments to secure required referrals and authorizations
- Serve as liaison between physicians and payers for peer-to-peer reviews
- Escalate denied or uncleared accounts according to policy
- Interview patients, families, or referring physicians to collect financial and demographic information
- Verify and reconcile demographic and insurance information with insurance carriers
- Refer self-pay or unresolved-insurance patients to Patient Financial Counseling
- Maintain confidentiality and comply with healthcare collection, regulatory, and organizational policies
- Handle telephone calls and emails according to customer-service standards
- Participate in training, quality audits, orientation of new personnel, and process-improvement initiatives
- Contact IT Help Desk or appropriate vendors regarding faulty systems or equipment
- Perform other related duties as assigned
Requirements:
- High school diploma or GED required
- 4-5 years of office experience, specifically in a high volume data entry office, customer service call center or health care office or hospital administration
- Experience using insurance payer websites (e.g., Blue Cross Blue Shield, Medicare)
- 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 workload when processing referrals and authorization requests per guidelines and within specified Turn Around Timeframes
- Thorough knowledge of financial clearance process
- Familiarity with insurances, referral authorizations and third-party billing procedures
- Basic medical terminology and ICD-9/CPT coding knowledge helpful
- Knowledge of and experience within Epic preferred
- Technical proficiency with Epic work queues and ancillary systems, including ADT/Prelude/Grand Centrale
- Basic computer proficiency, including Microsoft Excel, Word, Outlook, and Zoom
- Knowledge of medical terminology and/or coding
- Ability to maintain strict confidentiality of personal/health sensitive information
- Associate’s Degree or higher preferred
- Customer service experience preferred
- Bilingual preferred
Benefits:
- Medical, dental, vision, and pharmacy benefits
- 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
- Educational offerings sponsored by BMC
- Development opportunities
- Remote work
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