Prior Authorization Specialist - Per Diem

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 members' and providers' needs. Authorizes certain specified services under supervision according to departmental guidelines and forwards specified requests to clinicians for review. This role belongs to the Revenue Cycle Patient Access team and coordinates all financial clearance activities, including pre-registration, insurance verification, referral authorization, and precertification.

The Prior Authorization Specialist ensures timely access to care while maximizing hospital reimbursement, adhering to quality assurance guidelines and productivity standards. This is a remote, part-time position.

Responsibilities

• Prioritizes incoming prior authorization requests.
• Processes incoming requests, including authorizing specified services as outlined in departmental policies 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 requests.
• 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 necessary patient and/or payer-specific financial clearance elements.
• Maintains knowledge of and complies with insurance companies’ requirements for obtaining prior authorizations, referrals, and pre-certifications.
• Acts as a subject matter expert in navigating BMC and payer policies to secure appropriate approvals (e.g., authorizations, pre-certs, referrals).
• Obtains and documents all referral/prior authorizations for scheduled services prior to admission within Epic.
• Collaborates with primary care practices, specialty practices, referring physicians, insurance carriers, and patients to ensure required managed care referrals and prior authorizations are obtained and recorded in practice management systems.
• Ensures approval numbers are appropriately linked to relevant patient appointments/visits.
• Collaborates with patients, providers, and departments to obtain necessary information and payer permissions prior to scheduled services.
• Serves as a liaison between physicians and payers for peer-to-peer reviews when needed.
• Escalates accounts that have been denied or will not be financially cleared as outlined by department policy.
• Interviews patients, families, or referring physicians via telephone to obtain necessary financial and demographic information for reimbursement and compliance.
• Ensures updated demographic and insurance information is accurately recorded in registration systems for primary, secondary, and tertiary insurances.
• Reviews registration and insurance information in systems and reconciles with information from insurance carriers; validates updates using available resources.
• Contacts patients for clarifications or follow-up while maintaining a customer-friendly approach.
• Refers self-pay patients or those with unresolved insurance to Patient Financial Counseling.
• Maintains confidentiality of patient financial and medical records; adheres to state and federal laws regulating healthcare collections and enterprise confidentiality policies.
• Participates in educational offerings and complies with organizational workflows, policies, and procedures.
• Demonstrates knowledge and skills necessary to provide a high level of customer experience aligned with BMC management expectations.
• Recognizes situations requiring escalation to the Supervisor.
• Learns other roles and processes to assist with process improvement initiatives.
• Consistently meets productivity and quality expectations.
• Handles ACD telephone calls and emails in a timely fashion, following applicable scripting and customer service standards.
• Regularly undergoes quality audits to achieve required standards.
• Reports faulty systems or hardware to the Help Desk or appropriate vendor and notifies supervisor if issues are not addressed.
• Communicates effectively and courteously with all internal and external customers.
• Attends required hospital and department training.
• Assists in the orientation of new personnel under the direction of a manager or supervisor.
• Performs other related duties as assigned or required.
• Adheres to all of BMC’s RESPECT behavioral standards.

Requirements

• High school diploma or GED required; Associate’s Degree or higher preferred.
• 4-5 years of office experience in a high-volume data entry office, customer service call center, or healthcare office/hospital administration.
• Experience using insurance payer websites (e.g., Blue Cross Blue Shield, Medicare).
• Customer service experience preferred.
• Experience with insurance verification, prior authorization, pre-certification, and financial clearance processes.

Skills

• Bilingual preferred.
• Ability to process a high volume of requests with 95% or greater accuracy.
• Ability to prioritize workload when processing referrals and authorization requests per guidelines and within specified turn-around timeframes.
• Effective collaboration skills.
• Strong oral and written communication skills.
• Thorough knowledge of the financial clearance process, including familiarity with insurances, referral authorizations, and third-party billing procedures.
• Knowledge of basic medical terminology and ICD-9/CPT coding is helpful.
• Excellent interpersonal skills to build and maintain strong relationships with managers, colleagues, and third-party payers.
• Self-directed, highly organized, and able to multitask while managing complex processes with a sense of urgency.
• Ability to make independent decisions under pressure.
• Excellent judgment, diplomacy, collaboration, partnering, teamwork, and customer service skills.
• Ability to maintain confidentiality of all personal/health-sensitive information.
• Comfortable with ambiguity and exhibits strong decision-making and attention to detail.
• Knowledge of and experience with Epic preferred, including proficiency in ADT/Prelude/Grand Centrale work queues.
• Basic computer proficiency, including Microsoft Suite applications (Excel, Word, Outlook) and Zoom.
• Knowledge of medical terminology and/or coding.

Pay

Compensation range: $25.42–$30.97 per hour. This range is based on minimum job qualifications; actual base pay considers education, experience, and licensure/certifications directly related to the position.

Benefits

• Medical, dental, vision, and pharmacy benefits.
• Flexible Spending Accounts.
• 403(b) savings match.
• Earned time cash out.
• Paid time off.
• Career advancement opportunities.
• Resources to support employee and family wellbeing.