Prior Authorization Specialist

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Screen and prioritize requests for prior authorization and coordination of specialized services.

• Verify patient insurance and secure authorizations through Epic and payer portals.

• Process authorization requests for inpatient, outpatient, and ancillary services.

• Authorize specified services under the supervision of a manager and refer clinically complex requests for further review.

• Coordinate activities related to financial clearance, pre-registration, demographic, and insurance verification.

• Obtain referral authorizations and precertification numbers.

• Respond to ACD calls and emails from providers, patients, and departments.

• Verify member eligibility and enter necessary information into CCMS or Facets.

• Inform callers and providers about network providers, services, benefits, and authorization outcomes.

• Monitor and manage registration and prior-authorization work queues.

• Obtain, document, and link referrals and prior authorizations to scheduled services in Epic.

• Collaborate with patients, providers, physicians, practices, insurance carriers, case management, and Patient Financial Counseling.

• Coordinate peer-to-peer reviews and escalate denied or financially uncleared accounts.

• Interview patients, families, or referring physicians to gather demographic, financial, and insurance information.

• Reconcile registration and insurance information with payer records.

• Refer self-pay or unresolved insurance patients to Patient Financial Counseling.

• Maintain confidentiality and adhere to healthcare collection laws, regulatory policies, and organizational procedures.

• Meet expectations for productivity, quality, accuracy, and turnaround times.

• Participate in training, quality audits, onboarding, and process improvement initiatives.

• Report defective systems or equipment to the relevant support teams.

• Perform other related responsibilities as assigned.

⛳️ Requirements

• High school diploma or GED is required.

• An Associate’s Degree or higher is preferred.

• 4-5 years of experience in a high-volume data entry office, customer service call center, healthcare office, or hospital administration is required.

• Experience with Meditech is strongly preferred.

• Familiarity with insurance payer websites, such as Blue Cross Blue Shield and Medicare.

• Customer service experience is preferred.

• Experience in insurance verification, prior authorization, pre-certification, and financial clearance processes.

• Bilingual candidates are preferred.

• Ability to process high-volume requests with an accuracy rate of 95% or higher.

• Ability to prioritize workload and process referrals and authorization requests within designated turnaround times.

• Strong oral and written communication skills.

• Comprehensive knowledge of the financial clearance process.

• Familiarity with insurance, referral authorizations, and third-party billing procedures.

• Basic knowledge of medical terminology and ICD-9/CPT coding is helpful.

• Experience with Epic is preferred.

• Technical proficiency with Epic work queues and ancillary systems, including ADT/Prelude/Grand Centrale.

• Proficiency in Microsoft Suite, especially Excel, Word, Outlook, and Zoom.

• Ability to maintain strict confidentiality regarding personal, health-sensitive, financial, and medical information.

• Capability to make independent decisions under pressure.

• Ability to multitask, manage complex processes, and maintain attention to detail.

🏝️ Benefits

• Medical, dental, vision, and pharmacy benefits.

• Contract increases.

• Flexible Spending Accounts.

• 403(b) savings matches.

• Earned time cash out.

• Paid time off.

• Opportunities for career advancement.

• Resources to support employee and family wellbeing.

• Educational offerings and various development opportunities.

• Remote work arrangement.