Prior Authorization Specialist I

POSITION SUMMARY :

The Inpatient Verification Specialist role belongs to the Revenue Cycle Patient Access team and is responsible for coordinating all financial clearance activities by navigating all referral, precertification, and/or authorization requirements as outlined in payer-specific guidelines and regulations. The role plays an important dual role by helping to coordinate patient 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 inpatient financial counselors.

Position : Prior Authorization Specialist I Department : Insurance Verification Schedule : Part Time (M-F 10:30A-5P)

ESSENTIAL RESPONSIBILITIES / DUTIES : Monitors accounts routed to precertification and prior authorization work queues and clears work queues by obtaining all payer specific financial clearance requirements in accordance with established management guidel ines.

Maintains knowledge of and complies with insurance companies’ requirements for obtaining pre-certifications/prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clea rance.

Acts as subject matter experts in navigating both the BMC Community and the payer world to get the right “permi ssions” (authorizations, pre-certs, referrals, for example) for the care plan to proceed.

The Impatient Verification Specialist is an important part of the larger team and helps clinicians understand what payer requirements are necessary for the widest possible patient access to services.

Supports BMC staff at all levels for hands-on help understanding and navigating financial clearance i ssues.

Uses appropriate strategies to underscore the most efficient process to obtaining authorizations, including on lin e databases, electronic correspondence, faxes, and phone calls.

Obtains and clearly documents all pre-certifications/prior authorizations for scheduled services prior to admissio n within the Epic environment.

Collaborates with patients, providers, and departments to obtain all necessary information and payer permissio ns prior to patients’ scheduled services.

Communicates with patients, providers, and other departments such as Utilization Review to resolve any issues or problems with obtaining required pre-certifications/prior authorizations.

Escalates emergent and elective accounts that have been denied or will not be financially cleared within 3 days of admission as outlined by department policy

Keeps current on CMS requirements and guidelines.

Coordinates with patients and Patient Financial Counseling to initiate/process Charity Care applications as needed.

Maintains confidential ity of patient’s financial and medical records: adheres to the State and Federal laws regula ting collection in healthcare, adheres to enterprise and other regulatory confidentiality policies and advises management of any potential compliance issues immed iately.

Participates in educational offerings sponsored by BMC or other development opportunities as assigned/availa ble and complies with all applicable organizational workflows, as well as established policies and procedu res.

Performs other duties as assigned by Management.

Demonstrates knowledge & skills necessary to provide level of customer experience as alig ned with BMC management expectations.

Demonstrates the ability to recognize situations that require escalation to the Supervisor.

Estab lishes relationships and effectively collaborates with revenue cycle staff to support continuous improvement aligned with BMC management expectations as outlined.

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.

Must adhere to all of BMC’s RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities require d).

JOB REQUIREMENTS

EDUCATION : High School Diploma or GED required, Associates degree or higher preferred.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED : Case manager and/or coding certification desirable

EXPERIENCE : 4-5 years medical billing/denials/coding/and/or inpatient admitting experience desirable

KNOWLEDGE AND SKILLS: General knowledge of healthcare terminology and CPT-ICD10 codes.

Complete understanding of insurance is preferred.

Requires excellent verbal communication skills, and the ability to work in a complex environmen t with varying points of view.

Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to de tail.

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 Central, HB & PB Resolute.

D emons trates proficiency in Microsoft Suite applications, specifically Excel, Word, and Outlook.

Displays a thorough knowledge of various sections withi n the work unit in order to provide assistance and back-up coverage as directed.

Displays a deep understanding of Revenue Cycle processes and applies knowledge to meet and maintain productivity standards as outlined b y Management.

Compensation Range: $25.42- $30.97 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Equal Opportunity Employer/Disabled/Veterans According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.