Prior Authorization Specialist I

📋 Description

• • As a Prior Authorization Specialist I at BMC Software, Inc., you will play a critical role within the Revenue Cycle Patient Access team, serving as a key coordinator for all financial clearance activities. This remote position is integral to ensuring timely access to care for patients while simultaneously maximizing hospital reimbursement. You will be responsible for navigating the complex landscape of pre-registration, including acquiring and validating essential patient demographic and insurance information, and obtaining necessary referral authorizations or precertification numbers.
• • Your primary focus will be on screening prior-authorization and coordination of specialized services requests within the medical care management program. This encompasses a broad spectrum of requests for inpatient, outpatient, and ancillary services. You will diligently adhere to established policies and procedures, ensuring compliance with performance and regulatory standards, and contributing to cost-effective and appropriate healthcare delivery.
• • A significant aspect of your role will involve maintaining up-to-date knowledge of network resources, enabling you to effectively guide members and providers toward the most suitable options for their needs. Under the supervision of the manager, you will be empowered to authorize certain specified services in accordance with departmental guidelines. For requests that necessitate clinical judgment, you will expertly refer them to the appropriate clinician for review and processing, following standard workflows.
• • You will be the first point of contact for providers and other departments calling into the ACD line, adeptly answering inquiries and redirecting calls as needed. This requires excellent communication skills and a thorough understanding of the authorization process.
• • The role demands a commitment to quality assurance and the ability to meet established productivity standards to support the overall performance expectations of the work unit. You will report to the Patient Access Supervisor and engage in crucial collaboration with various stakeholders involved in the financial clearance process. These stakeholders include, but are not limited to, insurance company representatives, patients, physicians, Boston Medical Center (BMC) practice staff, case management, and Patient Financial Counseling.
• • Key responsibilities include prioritizing incoming Prior Authorization requests, processing them efficiently by authorizing specified services as per departmental policies, procedures, and workflow guidelines. You will also be responsible for referring authorization requests that require clinical judgment to the Prior Authorization Clinician, Manager, or Medical Director.
• • You will be expected to consistently meet or exceed position metrics and Turn-Around Timeframes while managing a full caseload. A vital part of your role will be supporting Prior Authorization Clinicians, ensuring a seamless workflow and efficient processing of requests.
• • When handling ACD line calls, you will verify member eligibility and accurately enter the necessary information into CCMS or Facets to fulfill the caller’s request. You will identify and inform callers about network providers, available services, and member benefits, ensuring they have the information needed to make informed decisions.
• • You will inform providers of decisions according to department procedures and coordinate the resolution of escalated member or provider inquiries related to Prior Authorization. This requires a proactive approach to problem-solving and effective communication.
• • A crucial element of your role is to work collaboratively with members, providers, and key departments to foster a clear understanding of Prior Authorization requirements and processes. You will maintain a general understanding of applicable sections of member handbooks and evidence of coverage to provide accurate information.
• • You will actively monitor accounts routed to registration and prior authorization work queues, clearing them by obtaining all necessary patient and/or payer-specific financial clearance elements in accordance with established management guidelines. This ensures that all prerequisites for care are met.
• • You will maintain a comprehensive understanding of and comply with insurance companies’ requirements for obtaining prior authorizations/referrals, completing other activities to facilitate all aspects of financial clearance. You will act as a subject matter expert in navigating both BMC and payer policies to secure the appropriate approvals (authorizations, pre-certs, referrals) for scheduled care.
• • The Authorization Specialist is an indispensable part of the larger patient care team, assisting clinicians in understanding payer requirements to facilitate the widest possible patient access to services. You will employ effective strategies to streamline the process of obtaining insurance verification, authorizations, and referrals, utilizing online databases, electronic correspondence, faxes, and phone calls.
• • You will obtain and clearly document all referral/prior authorizations for scheduled services prior to admission within the Epic environment. This meticulous documentation is crucial for compliance and reimbursement.
• • Collaboration is key: you will work closely with primary care practices, specialty practices, referring physicians, primary care physicians, insurance carriers, patients, and other parties to ensure that required managed care referrals and prior authorizations for specified specialty visits and other services are obtained and appropriately recorded in the relevant practice management systems prior to scheduled patient visits or retro-actively if not in place at the time of the appointment/visit. Ensuring that approval numbers are correctly linked to the relevant patient appointment/visit is paramount.
• • You will collaborate with patients, providers, and departments to gather all necessary information and secure payer permissions before patients’ scheduled services. You will serve as a liaison between physicians and payers for peer-to-peer reviews when needed, and escalate accounts that have been denied or will not be financially cleared as per department policy.
• • Whenever possible, you will interview patients, families, or referring physicians via telephone in advance of the patient’s appointment/visit to obtain essential information, including financial and demographic details required for reimbursement and compliance. You will ensure that all updated demographic and insurance information is accurately recorded in the appropriate registration systems for primary, secondary, and tertiary insurances, reconciling this information with data from insurance carriers.
• • For any insurance updates, you will utilize available resources to validate the information, including plan eligibility, primary care physician, subscriber information, employer information, and appointment/visit details. You will contact patients as necessary for clarifications, always maintaining a sensitive and customer-friendly approach. For self-pay patients or those with unresolved insurance, you will refer them to Patient Financial Counseling.
• • You will maintain the strictest confidentiality of patient financial and medical records, adhering to all State and Federal laws regulating healthcare collections and enterprise/regulatory confidentiality policies. You will promptly advise management of any potential compliance issues.
• • You will participate in educational offerings and development opportunities, complying with all applicable organizational workflows, policies, and procedures. You will demonstrate the knowledge and skills necessary to provide the expected level of customer experience and recognize situations requiring escalation to the Supervisor. You will proactively learn other roles and processes and contribute to process improvement initiatives. Consistently meeting productivity and quality expectations is essential. You will handle ACD telephone calls and emails in a timely manner, following applicable scripting and customer service standards, appropriately managing all calls by either resolving them or referring them to the correct party. Regular quality audits will be conducted to ensure adherence to required standards. You will report system or hardware issues to the Help Desk and notify your supervisor if problems are not addressed promptly. You will communicate effectively and courteously with all internal and external customers and attend all necessary hospital and department training. You will assist in the orientation of new personnel under the direction of a manager or supervisor and perform other related duties as assigned or required.