Prior Authorization Specialist

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

📋 Description

• Assess and prioritize incoming requests for prior authorization and specialized services.

• Process authorization requests and approve specified services in accordance with departmental policies.

• Refer cases that require clinical judgment to the Prior Authorization Clinician, Manager, or Medical Director.

• Achieve position metrics and turnaround time targets while managing a full caseload.

• Assist Prior Authorization Clinicians in their duties.

• Handle ACD calls, verify member eligibility, and input data into CCMS or Facets.

• Identify and clarify network providers, services, and member benefits.

• Communicate authorization decisions to providers.

• Facilitate the resolution of escalated inquiries from members and providers.

• Monitor registration and prior authorization work queues while obtaining financial clearance elements.

• Acquire and document referrals and prior authorizations in Epic.

• Collaborate with practices, physicians, insurance carriers, patients, and departments to secure necessary referrals and authorizations.

• Act as a liaison between physicians and payers for peer-to-peer reviews.

• Escalate denied or uncleared accounts as per policy guidelines.

• Conduct interviews with patients, families, or referring physicians to gather financial and demographic information.

• Verify and reconcile demographic and insurance details with insurance carriers.

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

• Uphold confidentiality and adhere to healthcare collection, regulatory, and organizational policies.

• Manage phone calls and emails in line with customer service standards.

• Engage in training, quality audits, orientation for new staff, and initiatives for process improvement.

• Contact the IT Help Desk or relevant vendors about malfunctioning systems or equipment.

• Perform additional related tasks as assigned.

⛳️ Requirements

• High school diploma or GED is mandatory.

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

• Familiarity with insurance payer websites (e.g., Blue Cross Blue Shield, Medicare) is required.

• Experience with insurance verification, prior authorization, pre-certification, and the financial clearance process is necessary.

• Capability to process a high volume of requests with an accuracy rate of 95% or above.

• Ability to prioritize workload while processing referrals and authorization requests according to guidelines and specified turnaround times.

• Comprehensive understanding of the financial clearance process.

• Knowledge of insurances, referral authorizations, and third-party billing procedures.

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

• Experience with Epic software is preferred.

• Technical skills with Epic work queues and related systems, including ADT/Prelude/Grand Centrale, are necessary.

• Basic computer skills, including proficiency in Microsoft Excel, Word, Outlook, and Zoom, are essential.

• Knowledge of medical terminology and/or coding is a plus.

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

• An Associate’s Degree or higher is preferred.

• Customer service experience is preferred.

• Bilingual candidates are preferred.

🏝️ Benefits

• Medical, dental, vision, and pharmacy benefits.

• Opportunities for contract increases.

• Flexible Spending Accounts.

• 403(b) savings matches.

• Cash out for earned time.

• Paid time off.

• Career advancement opportunities.

• Resources to support employee and family wellbeing.

• Educational offerings sponsored by BMC.

• Development opportunities.

• Option for remote work.