Prior Authorization Specialist I - Patient Access Services

CareStream Advisory Group's mission is to help healthcare professionals find rewarding opportunities that align with their care philosophy. We identify and validate positions directly from healthcare employers.

About the role

Responsible for screening prior-authorization and coordination of specialized services requests in the medical care management program, including a broad range of requests for inpatient, outpatient, and ancillary services. Adheres to policies and procedures to comply with performance and compliance standards and ensure cost-effective and appropriate healthcare delivery. Maintains current knowledge of network resources for referral and linkage to member's and provider's needs. Authorizes certain specified services, under supervision, according to departmental guidelines. Forwards specified requests to the clinician for review and processing. Answers ACD line calls from providers and other departments and redirects as needed.

The Prior Authorization Specialist role belongs to the Revenue Cycle Patient Access team and coordinates all financial clearance activities, including pre-registration (acquiring or validating patient demographic, insurance, and other required elements), insurance verification, referral authorization, and precertification. Ensures timely access to care while maximizing hospital reimbursement. This role requires adherence to quality assurance guidelines and established productivity standards. Reports to the Patient Access Supervisor and collaborates with stakeholders such as insurance representatives, patients, physicians, practice staff, case management, and Patient Financial Counseling.

This is a full-time, remote position.

Responsibilities

• Prioritizes incoming Prior Authorization requests.
• Processes incoming requests, including authorizing specified services as outlined in departmental policies, procedures, and workflow guidelines.
• Refers authorization requests requiring clinical judgment to Prior Authorization Clinician, Manager, or Medical Director.
• Meets or exceeds position metrics and Turn-Around Timeframes while maintaining a full caseload.
• Supports Prior Authorization Clinicians.
• Answers ACD line calls, verifies member eligibility, and enters information into CCMS or Facets to complete the caller's request.
• Identifies and informs callers of network providers, services, and available member benefits.
• Informs providers of decisions per department procedure.
• Coordinates resolution of escalated member or provider inquiries related to Prior Authorization.
• Works with members, providers, and key departments to promote understanding of Prior Authorization requirements and processes.
• Maintains a general understanding of applicable sections of member handbooks and evidence of coverage.
• Monitors accounts routed to registration and prior authorization work queues; clears work queues by obtaining all necessary patient and/or payer-specific financial clearance elements.
• Maintains knowledge of and complies with insurance companies' requirements for obtaining prior authorizations/referrals; completes activities to facilitate financial clearance.
• Acts as a subject matter expert in navigating BMC and payer policies to secure appropriate approvals (e.g., authorizations, pre-certs, referrals) for scheduled care.
• Helps clinicians understand payer requirements to ensure the widest possible patient access to services.
• Uses appropriate strategies (online databases, electronic correspondence, faxes, phone calls) to obtain insurance verification, authorizations, and referrals efficiently.
• Obtains and clearly documents all referral/prior authorizations for scheduled services prior to admission within the Epic environment.
• Collaborates with primary care practices, specialty practices, referring physicians, insurance carriers, patients, and other parties to ensure required managed care referrals and prior authorizations are obtained and recorded in practice management systems before or retroactively for patient visits.