Prior Authorization Specialist

• Bachelors degree or equivalent preferred; high school diploma required.
• 2 years experience in hospital settings such as Patient Access Doctors Office Inpatient Unit Patient Accounts Billing or at a related type of medical institution or medical payer.
• Knowledge of insurance and/or managed care authorization requirements is preferred.
• Knowledge of revenue cycle particularly regarding 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.

Responsibilities:

• 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 Childrens 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 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.
• Contact insurance companies managed care plans outside agencies and intermediaries to verify insurance coverage and 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 to understand which payers are contracted needs 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 is entered via many sources and needs 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 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 a 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 doctors office of any additional clinical requests including notes that are lacking tried and true therapies/refrainment e.g. Orthopedic or Neuro Spine cases.
• Advises uninsured and underinsured patients regarding available programs.
• Makes appropriate referrals to the Patient Financial Services Department in a timely manner so that coverage may be secured ASAP and the accompanying authorization if any is submitted as soon as the Payer source is identified.
• Advises and refers to Patient Financial Services when it appears a patient liability estimate is in order. Works closely with PFS Practice staff and the patient or his/her family to aid in an understanding of liability and informs of the expectations of Brigham Health regarding collection of liability.
• Reviews and follows-up on all emergency and unscreened admissions as soon as possible within 24 business hours of admission at the latest to identify and minimize financial risk to the institution.
• Follow all cases throughout the duration of the admission working with the Utilization Review (UR) Department every few days in Ontrac to send concurrent review clinicals. Must connect with Payer continually throughout the admission for updated authorization days alerting UR to any medical necessity denials so they can conduct in-house Peer-to-Peer Review.
• Reviews RTE eligibility system in EPIC throughout admission for any Payer changes or discrepancies and follow-up for new prior authorization when Payer changes mid-admission.
• Review cases daily for patient class changes e.g. coverts from outpatient to inpatient to modify or request authorization updates.
• Reviews Ontrac list daily for exceptions which include some of the above but in addition expected date changes in surgery primary and secondary payer changes high-risk high dollar accounts and other important notifications.
• Scan authorization-related information into Epic Media Manager and document notes in accordance with QA Metrics.
• Works closely with the Authorization Denials Team to avert write-offs by researching cases and providing backup documentation for possible prior auth appeals.
• Stays current with Payer changes in authorization requirements and restrictions e.g. additional CPT procedure codes now requiring authorizations additional tried therapies etc.
• Maintains a daily workflow of Ontrac work lists and keeps Epic auth/cert fields and notes updated before throughout and post-service until the case is in final secured status and authorization is complete for billing purposes.
• 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.

Interactions/Interpersonal Skills:

• Demonstrated excellent customer service abilities with awareness of the sensitivities related to the work of the core function and its critical impact on patient experience and the hospital mission.
• Proficiency in oral and written communication.
• Heightened ability to effectively interact with various levels of the organization leveraging different styles to manage challenging communications with a diverse set of customers.
• Ability to work independently with minimal supervision.
• Able to identify when something needs to be escalated to Senior Management from case level to an identified thematic level.
• Commitment to collaborating within a functional team to advance efficiency and quality of work and drive towards departmental goals.
• Adeptness in assessing and solving problems excellent organizational skills and ability to multi-task and prioritize.
• Possess a continuous and nimble learning mindset to sustain self and team as trusted key subject matter experts in content.
• Demonstrated ability to enact good judgment tact sensitivity and the ability to function in a fast-paced constantly changing environment.
• Ability to maintain confidentiality regarding patients their medical histories demographic and fiscal information etc.