Prior Authorization Specialist I – Patient Access Services

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

📋 Description

• Oversee financial clearance tasks, which include pre-registration, verifying insurance, managing referrals, obtaining authorizations, and securing precertifications.

• Manage and prioritize incoming requests for prior authorization.

• Direct requests that necessitate clinical evaluation to the Prior Authorization Clinician, Manager, or Medical Director.

• Handle ACD calls, confirm member eligibility, and input information into CCMS or Facets.

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

• Communicate authorization decisions to providers and coordinate any escalated inquiries.

• Supervise registration and prior authorization queues to gather necessary financial clearance components.

• Navigate BMC and payer regulations to secure approvals for scheduled care.

• Acquire and document referrals and prior authorizations in Epic.

• Collaborate with practices, physicians, insurance companies, patients, and departments to obtain required permissions.

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

• Escalate denied or uncleared accounts in accordance with policy.

• Conduct interviews with patients, families, and referring physicians to gather demographic, financial, and insurance details.

• Validate and refresh demographic, insurance eligibility, subscriber, employer, and appointment data.

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

• Uphold confidentiality and adhere to healthcare collection regulations and policies.

• Manage telephone and email communications following customer service standards.

• Engage in training, quality audits, onboarding of new personnel, and initiatives for process enhancement.

• Report defective systems or equipment and carry out other assigned responsibilities.

⛳️ Requirements

• High school diploma or GED is mandatory.

• 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.

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

• Knowledge of insurance verification, prior authorization, pre-certification, and financial clearance procedures.

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

• Ability to prioritize tasks within designated turnaround times.

• Comprehensive understanding of the financial clearance process.

• Acquaintance with insurance, referral authorizations, and third-party billing methods.

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

• Experience with Epic is preferred.

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

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

• Ability to maintain strict confidentiality of personal and health-sensitive data.

• Capacity to make independent decisions under pressure and manage complex processes.

• Bilingual candidates are preferred.

🏝️ Benefits

• Comprehensive medical, dental, vision, and pharmacy benefits.

• Opportunities for contract increases.

• Flexible Spending Accounts.

• 403(b) savings matching.

• Option to cash out earned time.

• Paid time off.

• Opportunities for career progression.

• Resources available to promote employee and family well-being.

• Educational programs and development opportunities.

• Option for remote work.