Prior Authorization Specialist

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Hybrid position. Onsite location is MGB Assembly Row in Somerville, MA.

• Maintains expert-level knowledge about the 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 a 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.). There are differences across the entities that need to be realized.
  
  At times will need to coordinate DFCI and/or Boston Children's Hospital care that falls under special agreement with these entities.
• Uses independent judgment to make knowledgeable decisions in organizing with physician and office to respond to Medical Insurance inquiries and resolving conflicts concerning approval for surgical procedures in the OR.
• 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 with 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 tests and results, PT/OT notes, imaging results, and photos. Each type of surgery, as well as each insurance company, has different needs for information required to authorize the surgery and a review and understanding of all is needed to get approval for services.
• Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist, e.g., predetermination of medical necessity, need for out-of-network plan auth required in addition to the service/procedural auth, etc.
• Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and/or guidelines. Needs to understand which payers are contracted, need to determine what level and type of care, etc.
• 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. Data is entered via many sources and need to determine that all sources of information are accurate and updated as needed.
• Ability to identify incomplete clinical documentation that is needed to obtain approval for services. Interacts directly with physicians/clinicians/physicians’ office staff via EPIC, phone calls, and Outlook to identify what is missing and to collect further complete and appropriate patient data and clinical information necessary to submit to Medical Insurance to review for authorization of services scheduled.
• 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 Sr. Manager and/or Director, e.g., legal issues, complex financial issues, and patients with special insurance policy exclusions.
• Acts as liaison between physicians, insurance companies, and Patient Financial Services across multiple campuses.
• Monitors pending cases to ensure that approvals are obtained before admission or visit. Informs doctor’s office of any additional clinical requests, including…