Prior Authorization Specialist I – Patient Access Services

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

📋 Description

• Accountable for evaluating prior authorization and coordinating specialized service requests within the medical care management program, encompassing a diverse array of inpatient, outpatient, and ancillary service requests.

• Follows established policies and procedures to meet performance and compliance standards, ensuring cost-effective and suitable healthcare delivery.

• Keeps up-to-date with network resources to facilitate referrals and connect with both member and provider needs.

• Grants authorization for specific services under the oversight of the manager, in accordance with departmental guidelines.

• In line with standard workflows, routes designated requests to clinicians for their review and processing.

• Responds to ACD line inquiries from providers and other departments, redirecting as necessary.

• Manages all financial clearance activities by navigating pre-registration processes (including collecting or verifying patient demographics, insurance details, and other required elements along with insurance verification tasks), securing referral authorization, or obtaining precertification numbers.

• Guarantees prompt access to care while optimizing BMC hospital reimbursement.

• Assists Prior Authorization Clinicians.

• Takes ACD line calls, confirms member eligibility, and inputs the necessary information into CCMS or Facets to fulfill the caller’s requests.

• Identifies and informs callers about network providers, available services, and member benefits.

⛳️ Requirements

• High school diploma or GED is mandatory.

• Associate’s Degree or higher is preferred.

• A minimum of 4-5 years of office experience is required, particularly in high-volume data entry, customer service call centers, or healthcare office/hospital administration.

• Familiarity with Insurance payer websites (e.g., Blue Cross Blue Shield, Medicare, etc.) is essential.

• Preferred experience in customer service.

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

• Bilingual capabilities are preferred.

• Capacity to handle a high volume of requests with a 95% or greater accuracy rate.

• Ability to prioritize workload effectively while processing referrals and authorization requests per guidelines and within designated turn-around timeframes.

• In-depth knowledge of the financial clearance process is crucial.

• Awareness of insurance policies, referral authorizations, and third-party billing procedures is required.

• Understanding of basic medical terminology and ICD-9/CPT coding is advantageous.

• Must be self-motivated and highly organized, capable of multitasking, managing complex processes, and maintaining a strong sense of urgency.

• Must possess the ability to make independent decisions under pressure.

• Requires exceptional judgment, diplomacy, collaboration, teamwork, and customer service skills.

• Must maintain confidentiality regarding all personal and health-sensitive information.

• Knowledge of and experience with Epic is preferred.

• Basic computer skills are essential, including the ability to access, enter, and interpret computerized data/information, with proficiency in Microsoft Suite applications, especially Excel, Word, Outlook, and Zoom.

🏝️ Benefits

• Medical, dental, vision, and pharmacy coverage.

• Opportunities for contract increases.

• Flexible Spending Accounts.

• 403(b) savings matches.

• Earned time cash-out options.

• Paid time off.

• Career advancement opportunities.

• Resources available to support employee and family wellbeing.