Prior Authorization Specialist
Mass General Brigham
Summary
Reviews and processes prior authorization and referral requests for medical services in accordance with organizational policies and payer requirements. Ensures insurance eligibility, coordination of benefits, site-of-care compliance, and medical necessity by gathering and submitting complete medical documentation in alignment with HIPAA standards. Accurately documents authorization outcomes and all payer communications in the electronic health record.
Job description
Job Summary
Reviews and processes prior authorization and referral requests for medical services in accordance with organizational policies and payer requirements. Ensures insurance eligibility, coordination of benefits, site-of-care compliance, and medical necessity by gathering and submitting complete medical documentation in alignment with HIPAA standards. Accurately documents authorization outcomes and all payer communications in the electronic health record.
Essential Functions
- Work as part of a group to secure insurance authorizations in an appropriate timeframe. Collects and accurately enters information required by third parties for precertification for procedures, tests and imaging.
- When unclear, collaborates with ordering clinicians to ensure the proper CPT codes are submitted for prior authorization or referrals.
- Refer patients to financial counseling, as appropriate.
- Inform patient of authorization concerns prior to admission/procedure, coordinating with appropriate parties to facilitate authorization as appropriate, collaborating with other departments/offices to resolve complex authorization issues.
- Update authorization status in system and complete workflow.
- Respond to internal and external inquiries regarding authorization decisions and provide explanations as needed.
Qualifications
Education: High School Diploma or Equivalent required. Experience: Medical authorization or related field experience 1-2 years preferred and Epic experience 0-1 year preferred.
Knowledge, Skills and Abilities
- Excellent attention to detail and organizational skills.
- Strong communication and interpersonal skills.
- Knowledge of medical terminology and medical insurance benefits, including a complete understanding of the coordination of benefits.
- Familiarity with computer systems and databases.
- Ability to work independently and as part of a team.
- Ability to work in a fast-paced environment.
Additional Job Details
- M-F 8:30 AM- 5 PM EST schedule required for remote role
- A quiet, secure, stable, HIPAA-compliant workstation is required.
Requirements
- High School Diploma or Equivalent required
- Medical authorization or related field experience 1-2 years preferred
- Epic experience 0-1 year preferred
- Excellent attention to detail and organizational skills
- Strong communication and interpersonal skills
- Knowledge of medical terminology and medical insurance benefits
- Complete understanding of the coordination of benefits
- Familiarity with computer systems and databases
- Ability to work independently and as part of a team
- Ability to work in a fast-paced environment
Benefits
- Health Insurance
- Career Advancement Opportunities
- Differentials
- Premiums
- Bonuses
- Recognition Programs
Company overview
Mass General Brigham is one of the largest integrated healthcare delivery systems in the United States, formed through the merger of Massachusetts General Hospital and Brigham and Women's Hospital. Based in Boston, Massachusetts, this academic medical center system operates multiple hospitals, specialty facilities, and community health centers throughout New England. The organization is renowned for its world-class patient care, cutting-edge medical research, and comprehensive medical education programs. As a teaching affiliate of Harvard Medical School, Mass General Brigham trains the next generation of healthcare professionals while advancing medical science through groundbreaking research initiatives. The system provides a full continuum of healthcare services, from primary care and preventive medicine to complex specialty treatments and emergency services. With a focus on innovation and patient-centered care, Mass General Brigham consistently ranks among the top hospital systems in the nation for clinical excellence and research output.