Prior Authorization Specialist, Assembly Row - Somerville, United States - Brigham & Women's Hospital(BWH)

Brigham & Women's Hospital(BWH)

Verified Company

Somerville, United States

1 week ago

Posted by:

Mark Lane

beBee recruiter

Description

Prior Authorization Specialist, Assembly Row

What does a Prior Authorization Specialist do?

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The Prior Authorization Specialist (PAS) is an essential role responsible for facilitating exceptional patient experience, by securing authorizations for all scheduled services related to medical and surgical admissions across entities, including BWH OR procedures, BWFH OR procedures, FXB OR procedures and BWH/BWFH Endoscopy Suite procedures in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies.
The PAS is also responsible for securing authorizations for all Emergency and Urgent admissions to BWH and BWFH and for all Infusion Clinic Services for BWH and BWFH in accordance with standards established by the Department, Hospital, Medical Staff, and outside regulatory and accreditation agencies. This is a role that is critical to the organization's financial health, where responsibilities account for approximately over $4 Billion in revenue per fiscal year.

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Schedule:
Hybrid

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The individual can expect to work onsite for probationary period before moving to a hybrid work schedule (2-3 days in office).

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Benefits

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Full benefits: Medical, Dental, Vision, 403b retirement and match, Pension, STD, LTD
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PTO - 29 days per year
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Weekly pay
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Discounted MBTA pass
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Education Reimbursement

What does a day look like in this role?

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Maintains expert-level knowledge about industry; utilizes to manage pay models of complicated patient care plans and facilitates exceptional patient experiences as aligned with organizational values and mission.

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Interacts directly with EPIC Auth/Cert, Registration and Referral Shell, entering data accurately to coordinate all elements required for payment of services rendered, which includes, but is not limited to, appropriate CPT Procedure and Diagnosis codes, rendering Physician(s), level of care, and facility, i.e., across entities (BWH, BWFH, FXB, etc.). There are differences across the entities that need to be realized. At times will need to coordinate DFCI and/or Boston Children Hospital care that fall under special agreement with these entities. Uses independent judgement to make knowledgeable decisions in organizing with physician and office to respond to Medical Insurance inquiries and resolving conflicts concerning approval for surgical procedures in the OR.

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Consults with all levels of Hospital professionals, administrative and support staff, as well as patients, and representatives of other organizations where advanced expertise in communications is necessary to lead with tact, inclusivity, patience, and respect, while maintaining confidentiality and achieving consensus with the lens of exceptional patient experience.

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Interacts directly in EPIC Clinical System to extract necessary supporting clinical data to submit to Medical Insurance to secure authorization, e.g., clinical office notes, radiology reports, lab test and results, PT/OT notes, imaging results and photos. Each type of surgery, as well as each insurance company has different needs for information required to authorize the surgery, and review and understanding of all is needed to get an approval for services.

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Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits. Determines if any pre-admission/pre-visit requirements exist, e.g., predetermination of medical necessity, need for out of network plan auth required in addition to the service/procedural auth, etc.

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Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and/or guidelines. Need to understand which payers are contracted, need to determine what level and type of care, etc.

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Updates, obtains and/or verifies all pertinent data necessary to complete required registration, admission, demographic and financial information ensuring both timely access and accurate billing. Data is entered via many sources and need to determine that all sources of information are accurate, and update as needed.

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Ability to identify incomplete clinical documentation that is needed to obtain approval for services. Interacts directly with physicians/clinicians/physicians' office staff via EPIC, phone calls and Outlook to identify what is missing and to collect further complete and appropriate patient data and clinical information necessary to submit to Medical Insurance to review for authorization of services scheduled.

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Compiles, uploads, and submits all the above clinical information from Epic required to obtain preadmission approvals and precertification via the Medical Insurance Payer Portals.

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- **Determines when problematic preadmissions must be referred to the Sr. Manager and/or Director, e.g., legal issues, comple