Prior Authorization Specialist

🔥 21 hours ago

🇺🇸 United States – Remote

💵 $25 - $30 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• 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