Prior Authorization Specialist

GENERAL SUMMARY/ OVERVIEW STATEMENT:
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.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
* 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.
* Acts as subject matter expert and guide to broad employee base, particularly providers, to educate and communicate on requirements, processes and adjustments needed throughout the patient care journey.
* 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.
* 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.
* 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.
* 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.
* 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.
* 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.
* 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.
* Compiles, uploads, and submits all the above clinical information from Epic required to obtain preadmission approvals and precertification via the Medical Insurance Payer Portals.
* Determines when problematic preadmissions must be referred to the Sr. Manager and/or Director, e.g., legal issues, complex financial issues, and patients with special insurance policy exclusions.
* Acts as liaison between physicians, insurance company, Patient Financial Services across multiple campuses.
* Monitors pending cases to ensure that approvals are obtained prior to admission or visit. Informs doctor's office of any additional clinical requested, including notes that are lacking tried and true therapies/refrainment, e.g., Orthopedic or Neuro Spine cases.
* Advises uninsured and underinsured patients regarding available programs. Makes appropriate referrals to Patient Financial Services Department in a timely manner so that coverage may be secured ASAP and the accompanying authorization, if any, is submitted as soon as Payer source is identified.
* Advises and refers to Patient Financial Services when it appears a patient liability estimate is in order. Works closely with PFS, Practice staff and the patient or his/her family to aid in an understanding of liability and informs of the expectations of Brigham Health regarding collection of liability.
* Reviews and follows-up on all emergency and unscreened admissions as soon as possible, within 24 business hours of admission at the latest, to identify and minimize financial risk to the institution.
* Follows all cases throughout the duration of the admission, working with Utilization Review (UR) Department every few days in Ontrac to send concurrent review clinicals. Must connect with Payer continually throughout the admission for updated authorization days, alerting UR to any medical necessity denials so they can conduct in-house Peer to Peer Review.
* Reviews RTE eligibility system in EPIC throughout admission for any Payer changes or discrepancies and follow up for new prior authorization when Payer changes mid-admission.
* Reviews cases daily for patient class changes, e.g., coverts from outpatient to inpatient, to modify or request authorization updates.
* Reviews Ontrac list daily for exceptions which include some of the above, but in addition: expected date changes in surgery, primary and secondary payer changes, high risk high dollar accounts, and other important notifications.
* Scans authorization related information into Epic Media Manager and documents notes in accordance with QA Metrics. Works closely with Authorization Denials Team to avert write offs by researching cases and providing back-up documentation for possible prior auth appeals.
* Stays current with Payer changes in authorization requirements and restrictions, e.g., additional CPT procedure codes now requiring authorizations, or additional tried therapies, etc.
* Maintains a daily workflow of Ontrac work lists and keeps Epic auth/cert fields and notes updated prior to, throughout, and post service until case is in final secured status and authorization is complete for billing purposes.
* Maintains patient confidentiality and privacy by accessing patient information only to the extent necessary to fulfill assigned duties. All patient information must be kept private, confidential, and secure. All lists, reports, files, and documents must always be properly secured and stored. Interviews and examinations should be conducted in such a manner as to afford the patient reasonable audio and visual privacy.
* Adheres to Customer Service Standards (Service Excellence) by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors, and other staff members.
* Employs discretion when leaving answering machine messages, or sending faxes adhering to HIPAA rules
* Performs special projects, covers other services, and other tasks when necessary.
SKILLS & COMPETENCIES REQUIRED:
* Knowledge of revenue cycle particularly with regard to insurance reimbursement and managed care authorization and referral requirements
* Technical knowledge of specific legal and regulatory requirements and an understanding of complex third party and medical assistance policies and procedures
* Knowledge of the hospital information system with emphasis on registration and insurance verification, and accounts receivables programs
* Demonstrated excellent customer service abilities, with awareness of the sensitivities related to work of the core function, and its critical impact on patient experience and the hospital mission
* Proficiency in oral and written communication
* Heightened ability to effectively interact with various levels of the organization, leveraging different styles to manage challenging communications with a diverse set of customers
* Ability to work independently, with minimal supervision
* Able to identify when something needs to be escalated to Senior Management, from case level to an identified thematic level
* Commitment to collaborating within functional team to advance efficiency and quality of work and drive towards departmental goals
* Adeptness in assessing and solving problems, excellent organizational skills, and able to multi-task and prioritize
* Possess a continuous and nimble learning mindset, to sustain self and team as trusted key subject matter experts in content
* Demonstrated ability to enact good judgment, tact, sensitivity and the ability to function in a fast-paced, constantly changing environment
EDUCATION:
HS diploma required. Bachelor's degree preferred.
EXPERIENCE:
* Experience with, knowledge of, or desire to learn about elements of exceptional patient experience environments, as related to the function.
Preferred:
* Familiarity with a hospital legacy system, Microsoft Office, and SharePoint preferred
* Bilingual is helpful
* 2 years' experience in hospital setting such as Patient Access, Doctor's Office, Inpatient Unit, Patient Accounts Billing or at a related type medical institution or medical payer, e.g., BCBS, Tufts, etc. is preferred
* Knowledge of insurances and/or managed care authorization requirements a plus
* Knowledge of medical terminology and/or coding is preferred
WORKING CONDITIONS:
Professional Building with great amenities, off site from the Hospitals. High volume activity. Working with peers across subgroups may be required, e.g., Elective Team assists Urgent Team and vice versa. Hybrid model available after fully trained and consistently meeting productivity and quality metrics.

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