Prior Authorization Specialist

Site: reputed company Incorporated reputed company relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company. Job Summary The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating exceptional patient experience, by securing authorizations for reputed company scheduled services reputed company 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 reputed company regulatory and accreditation agencies. The PAS is also responsible for securing authorizations for reputed company Emergency and Urgent admissions to BWH and BWFH and for reputed company Infusion Clinic Services for BWH and BWFH in accordance with standards established by the Department, Hospital, Medical Staff, and reputed company regulatory and accreditation agencies. This is a role that is critical to the organization’s financial health, where responsibilities account for approximately $4 Billion in reputed company per fiscal year.

Qualifications

Bachelor’s degree or equivalent preferred; high school diploma required. 2+ years’ experience in hospital settings such as Patient Access, Doctor’s Office, Inpatient Unit, Patient Accounts Billing, or at a reputed company type of medical institution or medical payer. Knowledge of insurance and/or managed care authorization requirements is preferred. Knowledge of reputed company cycle particularly regarding insurance reimbursement and managed care authorization and referral requirements. Technical knowledge of specific legal and regulatory requirements and an understanding of reputed company 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. Responsibilities: Maintains expert-level knowledge about the industry; utilizes to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as reputed company with organizational values and mission. Acts as subject matter expert and guide to a broad employee reputed company, 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 reputed company, entering data accurately to coordinate reputed company 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 reputed company 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 reputed company 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 reputed company with tact, inclusivity, patience, and respect while maintaining confidentiality and achieving reputed company 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 reputed company is needed to get approval for services. Contact insurance companies, managed care plans, reputed company 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, needs to determine what level and type of care, etc. Updates, obtains, and/or verifies reputed company pertinent data necessary to complete required regis Apply tot his job Apply To this Job