Prior Authorization Specialist - Per Diem

📋 Description

• • As a Prior Authorization Specialist at BMC Software, Inc., you will play a critical role in ensuring patients receive timely access to necessary medical services while maximizing reimbursement for the organization. This remote, per diem position is integral to the Revenue Cycle Patient Access team, focusing on the crucial financial clearance activities that precede patient care.
• • Your primary responsibility will be to meticulously screen and coordinate prior authorization requests for a wide array of specialized services, encompassing inpatient, outpatient, and ancillary care. You will navigate complex medical care management programs, adhering strictly to established policies and procedures to meet performance and compliance standards, thereby ensuring cost-effective and appropriate healthcare delivery.
• • A key aspect of your role involves maintaining up-to-date knowledge of network resources, enabling you to effectively guide members and providers toward the most suitable options for their needs. You will be empowered to authorize certain specified services under the direct supervision of the manager, strictly following departmental guidelines. For requests that fall outside your authorization scope or require clinical judgment, you will expertly forward them to the appropriate clinician for review and processing, ensuring a seamless workflow.
• • You will be the first point of contact for providers and other departments calling into the ACD line, responsible for accurately verifying member eligibility and entering essential information into systems like CCMS or Facets to fulfill caller requests. This includes identifying and clearly communicating network providers, available services, and member benefits, as well as informing providers of decisions in accordance with departmental procedures.
• • A significant part of your day-to-day will involve managing incoming Prior Authorization requests, prioritizing them effectively to meet deadlines. You will process these requests, authorizing specified services as per departmental policies and workflows. For complex cases requiring clinical expertise, you will liaise with Prior Authorization Clinicians, Managers, or Medical Directors, ensuring all necessary steps are taken.
• • You are expected to consistently meet or exceed established position metrics and Turn-Around Timeframes, managing a full caseload with efficiency and accuracy. Your support extends to Prior Authorization Clinicians, assisting them in their critical tasks.
• • You will actively work with members, providers, and key internal departments to foster a clear understanding of Prior Authorization requirements and processes, acting as a subject matter expert. This involves maintaining a general understanding of applicable sections of member handbooks and evidence of coverage documents.
• • A core duty is to monitor accounts within 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 requires a thorough understanding of insurance company requirements for obtaining prior authorizations, pre-certifications, and referrals.
• • You will act as a vital liaison between physicians and payers, facilitating peer-to-peer reviews when necessary. You will also be responsible for escalating accounts that have been denied or cannot be financially cleared, following departmental policy precisely.
• • Proactively interviewing patients, families, or referring physicians via telephone before appointments or visits whenever possible is crucial. This allows you to gather all necessary information, including financial and demographic details vital for reimbursement and compliance.
• • Ensuring that all updated demographic and insurance information is accurately recorded in the appropriate registration systems (primary, secondary, and tertiary insurances) is paramount. You will reconcile this information with data from insurance carriers, utilizing available resources to validate updated insurance details, plan eligibility, PCP, subscriber information, employer details, and appointment specifics.
• • You will collaborate with patients, providers, and departments to secure all required information and payer permissions before scheduled services, ensuring a smooth patient journey. For self-pay patients or those with unresolved insurance issues, you will refer them to Patient Financial Counseling.
• • Maintaining the strictest confidentiality of patient financial and medical records, adhering to State and Federal laws, and advising management of any potential compliance issues immediately, are non-negotiable aspects of this role.
• • You will participate in educational offerings and development opportunities, demonstrating a commitment to continuous learning and professional growth. Consistently meeting productivity and quality expectations, handling ACD telephone calls and emails promptly, and undergoing regular Quality Audits are essential for success.
• • You will also be responsible for reporting system or hardware issues to the IT Help Desk and communicating effectively and courteously with all internal and external customers. Assisting in the orientation of new personnel and performing other related duties as assigned will round out your responsibilities, contributing to a collaborative and efficient team environment.