Prior-Authorization Spec; BMG

Prior-Authorization Spec (BMG) – Beacon Health System

Reports to the VP Patient Access. Responsibilities include evaluating designated referred services for authorization needs based on government and commercial payor requirements, disseminating clinical and coding documentation to complete the authorization process for appropriate reimbursement, and providing exceptional customer service to patients, families, visitors and BMG associates by communicating with empathy and clarity regarding the next step in care.

• Mission:
  We deliver outstanding care, inspire health, and connect with heart.
• Values:
  Trust. Respect. Integrity. Compassion.
• Service Goals:
  Personally connect. Keep everyone informed. Be on their team.

• Primary contact and resource for all designated prior authorization needs.
• Identify, collect, and coordinate clinical documentation to support the qualification of ordered services.
• Evaluate orders for insurance coverage and authorization requirements.
• Ensure carrier process requirements are met within contracted guidelines and timeliness.
• Ensure proper testing is performed and utilize tools in accordance with the provider’s desire and the testing criteria and guidelines including both insurance and modality ordering guidelines.
• Review and comply with additional requests.
• Validate completed authorizations to ensure the authorization corresponds with ordered service, code, time frame, and provider.
• Support the appeal process by communicating and coordinating resolution expectations with provider and authorization agent.
• Maintain standardized records to allow for effective coordinating, tracking, and reporting of department actions and metrics.
• Advocate for the customer by recognizing when to dispute a non‑desirable outcome regarding PA approval.
• Dispute and negotiate, when necessary, on behalf of BHS and the customer for a positive prior authorization outcome.
• Provide exceptional customer‑centric service during every encounter with patients, families, and associates.
• Use critical‑thinking skills to make decisions, identify problems, create solutions, and help implement change. Escalate concerns when necessary.
• Participate in performance improvement (i.e. follow established work systems, identify deviations or deficiencies in standards/systems/processes and communicate problems to supervisor or manage).
• Prioritize work effectively.
• Work at a fast pace and maintain accuracy.
• Understand the flow and rhythm of each task and connect each resulting convenient, connected and coordinated care.
• Use numerous software platforms (multiple EMR’s, insurance websites, referral database, scheduling software, etc.) to conduct tasks for patient care.

• Assisting others and/or accepting additional duties.
• Enhancing professional growth and development through in‑service meetings and educational programs as approved.
• Maintaining up‑to‑date knowledge and staying abreast of changes and updates as they occur (Insurance, Department and Processes changes).

• Attend and participate in department meetings and be accountable for all information shared.
• Complete mandatory education, annual competencies and department specific education within established time frames.
• Complete annual employee health requirements within established time frames.
• Maintain license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers maintain current BCLS (CPR), and other certifications as required by position/department.
• Consistently utilize universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adhere to regulatory agency requirements, survey process and compliance.
• Comply with established organization and department policies.
• Be available to work overtime in addition to working additional or other shifts and schedules when required.

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to…