Prior Authorization/referral Specialist

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.

ESSENTIAL RESPONSIBILITIES / DUTIES:

• 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 online 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 been denied or will not be financially cleared as outlined by department policy
• Interview patients, families or referring physicians via telephone in advance of the patient’s appointment/visit whenever possible, to obtain all necessary information, including but not limited to, financial and demographic information required for reimbursement and compliance for services rendered.
• Ensure that all updated demographic and insurance information is accurately recorded in the appropriate registration systems for primary, secondary and tertiary insurances.
• Review all registration and insurance information in systems and reconcile with information available from insurance carriers. For any insurance updates, utilize any available resources to validate the updated insurance information, insurance plan eligibility, primary care physician, subscriber information, employer information and appointment/visit information. Contact patients as necessary if clarifications or other follow-up is required, and at all times maintain sensitivity and a clear customer friendly approach.
• For self-pay patients or patients with unresolved insurance, and for financial counseling, refer patients Patient Financial Counseling.
• Maintains confidentiality of patient’s financial and medical records; adheres to the State and Federal laws regulating collection in healthcare; adheres to enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately.
• Participates in educational offerings sponsored by BMC or other development opportunities as assigned/available and complies with all applicable organizational workflows, as well as established policies and procedures.
• Demonstrates knowledge & skills necessary to provide level of customer experience as aligned with BMC management expectations.
• Demonstrates the ability to recognize situations that require escalation to the Supervisor.
• Takes opportunity to know and learn other roles and processes and works together to assist with process improvement initiatives as directed.
• Consistently meets productivity and quality expectations to align performance with assigned roles and responsibilities.
• Handle ACD telephone calls and emails in a timely fashion, following applicable scripting and customer service standards. Appropriately manage all calls by either working with the customer or referring the call to the appropriate party.
• Regularly undergo Quality Audits to achieve the required standard.
• Contact the Help Desk in the BMC Information Technology Department to report faulty systems or hardware. Notify area supervisor or manager if problem is not addressed in a timely manner. For other broken or malfunctioning equipment to be serviced, contact the appropriate vendor or department and notify supervisor.
• Communicate with all internal and external customers effectively and courteously.
• Attend all necessary hospital and department training as required.
• Assists in the orientation of new personnel under the direction of a manager or Supervisor.
• Perform other related duties as assigned or required.

EDUCATION:

• High school diploma or GED required.
• Associate’s degree or higher preferred

EXPERIENCE:

• 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.

KNOWLEDGE, SKILLS & ABILITIES (KSA):

• Bilingual preferred
• 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
• Effective collaboration skills
• Strong oral and written communication skills
• 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.
• Excellent interpersonal skills to build and maintain strong relationships with managers, colleagues, and third-party payers.
• 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.
• Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail.
• Knowledge of and experience within Epic is preferred.
• Demonstrates technical proficiency within assigned Epic work queues and applicable ancillary systems, including but not limited to: ADT/Prelude/Grand Centrale.
• Must be able to maintain strict confidentiality of all personal/health sensitive information.
• 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.

Equal Opportunity Employer/Disabled/Veterans