Prior Authorization Specialist I – Patient Access Services

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Boston Medical Center (BMC)

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1996

Boston Medical Center (BMC) is a 511-bed, equity-led academic medical center and a proud member of the Boston Medical Center Health System. BMC delivers a model of healthcare where innovative and equitable care empowers all patients to thrive. As a premier academic medical center in Boston, a national leader in clinical care, and the largest essential hospital in New England, BMC’s world-class clinicians provide comprehensive care in more than 70 specialties and subspecialties.

📋 Description

• 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. • Coordinates 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). • Ensures timely access to care while maximizing BMC hospital reimbursement. • 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.

🎯 Requirements

• High school diploma or GED required • Associate’s Degree or higher preferred • 4-5 years of office experience, specifically in either a high volume data entry office, customer service call center or health care office or hospital administration is required • Experience using Insurance payer websites (i.e Blue Cross Blue Shield, Medicare, etc.) • Customer service experience preferred • Experience with insurance verification, prior authorization, pre-certification and financial clearance process. • Bilingual preferred • 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 per guidelines and within specified Turn Around Timeframes • Thorough knowledge of financial clearance process is a must. • Familiarity with insurances, referral authorizations and third party billing procedures • Knowledge of basic medical terminology and ICD-9/CPT coding is helpful. • Must be self-directed and highly organized with the ability to multitask, manage complex processes, and maintain fair sense of urgency • Requires ability to make independent decisions under pressure. • Requires excellent judgment, diplomacy, collaboration, partnering, teamwork, and customer service skills. • Ability to maintain confidentiality of all personal/health sensitive information. • Knowledge of and experience within Epic is preferred. • Basic computer proficiency inclusive of ability to access, enter and interpret computerized data/information including proficiency in Microsoft Suite applications, specifically Excel, Word, Outlook and Zoom.

🏖️ Benefits

• medical, dental, vision, pharmacy • 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