Prior Authorization Specialist
Massachusetts General Physicians’ Organization - Boston, Massachusetts, us, 02298Work at Massachusetts General Physicians’ Organization
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Overview
Considering applying for this job Do not delay, scroll down and make your application as soon as possible to avoid missing out.The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating exceptional patient experience, by securing authorizations for all scheduled services related to medical and surgical admissions across entities, including BWH OR procedures, BWFH OR procedures, FXB OR procedures, and BWH/BWFH Endoscopy Suite procedures in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. The PAS is also responsible for securing authorizations for all Emergency and Urgent admissions to BWH and BWFH and for all Infusion Clinic Services for BWH and BWFH in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. This is a role that is critical to the organization’s financial health, where responsibilities account for approximately over $4 Billion in revenue per fiscal year.Principal Duties and Responsibilities:
Maintains expert-level knowledge about industry; utilizes to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as aligned with organizational values and mission.Acts as subject matter expert and guide to broad employee base, particularly providers, to educate and communicate on requirements, processes, and adjustments needed throughout the patient care journey.Interacts directly with EPIC Auth/Cert, Registration, and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, which includes, but is not limited to, appropriate CPT Procedure and Diagnosis codes, rendering Physician(s), level of care, and facility, i.e., across entities (BWH, BWFH, FXB, etc.).Consults with all levels of Hospital professionals, administrative and support staff, as well as patients, and representatives of other organizations where advanced expertise in communications is necessary to lead with tact, inclusivity, patience, and respect, while maintaining confidentiality and achieving consensus with the lens of exceptional patient experience.Interacts directly in EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization, e.g., clinical office notes, radiology reports, lab test and results, PT/OT notes, imaging results, and photos.Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits.Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and/or guidelines.Updates, obtains and/or verifies all pertinent data necessary to complete required registration, admission, demographic and financial information ensuring both timely access and accurate billing.Ability to identify incomplete clinical documentation that is needed to obtain approval for services.Compiles, uploads, and submits all the above clinical information from Epic required to obtain preadmission approvals and precertification via the Medical Insurance Payer Portals.Determines when problematic preadmissions must be referred to the Sr. Manager and/or Director.Acts as liaison between physicians, insurance company, Patient Financial Services across multiple campuses.Monitors pending cases to ensure that approvals are obtained prior to admission or visit.Advises uninsured and underinsured patients regarding available programs.Reviews and follows-up on all emergency and unscreened admissions as soon as possible, within 24 business hours of admission at the latest.Follows all cases throughout the duration of the admission.Maintains patient confidentiality and privacy by accessing patient information only to the extent necessary to fulfill assigned duties.Adheres to Customer Service Standards (Service Excellence) by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors, and other staff members.Performs special projects, covers other services, and other tasks when necessary.Qualifications
Skills & Competencies Required:Knowledge of revenue cycle particularly with regard to insurance reimbursement and managed care authorization and referral requirements.Technical knowledge of specific legal and regulatory requirements and an understanding of complex third party and medical assistance policies and procedures.Knowledge of the hospital information system with emphasis on registration and insurance verification, and accounts receivables programs.Demonstrated excellent customer service abilities.Proficiency in oral and written communication.Heightened ability to effectively interact with various levels of the organization.Ability to work independently, with minimal supervision.Able to identify when something needs to be escalated to Senior Management.Commitment to collaborating within functional team to advance efficiency and quality of work.Adeptness in assessing and solving problems, excellent organizational skills, and able to multi-task and prioritize.Possess a continuous and nimble learning mindset.Demonstrated ability to enact good judgment, tact, sensitivity.Education: HS Diploma or GED equivalent required. Bachelor's degree preferred.Experience: Experience with, knowledge of, or desire to learn about elements of exceptional patient experience environments, as related to the function.Preferred:
Familiarity with a hospital legacy system, Microsoft Office, and SharePoint preferred.Bilingual is helpful.2+ years’ experience in hospital setting such as Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing or at a related type medical institution or medical payer, e.g., BCBS, Tufts, etc. is preferred.Knowledge of insurances and/or managed care authorization requirements a plus.Knowledge of medical terminology and/or coding is preferred.Working Conditions: Professional Building with great amenities, off site from the Hospitals. High volume activity. Working with peers across subgroups may be required. Hybrid model available after fully trained and consistently meeting productivity and quality metric.MGH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.
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