About the position 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.

Responsibilities

• 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.
• Supports Prior Authorization Clinicians.
• 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 as 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 experts in navigating both the BMC and payer policies to get the appropriate approvals (authorizations, pre-certs, referrals, for example) for the scheduled care to proceed.
• The Authorization Specialist is an important part of the larger patient care team and helps clinicians understand what payer requirements are necessary for the widest possible patient access to services.
• Uses appropriate strategies to underscore the most efficient process to obtaining insurance verification, authorizations and referrals, including on line 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, primary care physicians, insurance carriers, patients and any other parties to ensure that required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems for patient appointments/visits prior to scheduled patient visits or retro-actively if not in place at the time of the appointment/visit.
• Ensure that approval numbers are appropriately linked to the relevant patient appointment/visit.
• Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients’ scheduled services.
• Liaison between physician and payer for peer to peer review when needed
• Escalates accounts that have b