Prior Authorization Specialist I

• Monitors accounts routed to precertification and prior authorization work queues and clears work queues by obtaining all payer specific financial clearance requirements in accordance with established management guidelines.

• Maintains knowledge of and complies with insurance companies’ requirements for obtaining pre-certifications/prior authorizations/referrals, and completes other activities to facilitate all aspects of financial clearance.

• Acts as subject matter experts in navigating both the BMC Community and the payer world to get the right “permissions” (authorizations, pre-certs, referrals, for example) for the care plan to proceed.

• The Impatient Verification Specialist is an important part of the larger team and helps clinicians understand what payer requirements are necessary for the widest possible patient access to services.

• Supports BMC staff at all levels for hands-on help understanding and navigating financial clearance issues.

• Uses appropriate strategies to underscore the most efficient process to obtaining authorizations, including on line databases, electronic correspondence, faxes, and phone calls.

• Obtains and clearly documents all pre-certifications/prior authorizations for scheduled services prior to admission within the Epic environment.

• Collaborates with patients, providers, and departments to obtain all necessary information and payer permissions prior to patients’ scheduled services.

• Communicates with patients, providers, and other departments such as Utilization Review to resolve any issues or problems with obtaining required pre-certifications/prior authorizations.

• Escalates emergent and elective accounts that have been denied or will not be financially cleared within 3 days of admission as outlined by department policy

• Keeps current on CMS requirements and guidelines.

• Coordinates with patients and Patient Financial Counseling to initiate/process Charity Care applications as needed.

• Maintains confidentiality of patient’s financial and medical records: adheres to the State and Federal laws regulating collection in healthcare, adheres to enterprise and other regulatory confidentiality policies and advises management of any potential compliance issues immediately.

• Participates in educational offerings sponsored by BMC or other development opportunities as assigned/available and complies with all applicable organizational workflows, as well as established policies and procedures.

• Performs other duties as assigned by Management.

• Demonstrates knowledge & skills necessary to provide level of customer experience as aligned with BMC management expectations.

• Demonstrates the ability to recognize situations that require escalation to the Supervisor.

• Establishes relationships and effectively collaborates with revenue cycle staff to support continuous improvement aligned with BMC management expectations as outlined.

• Takes opportunity to know and learn other roles and processes, and works together to assist with process improvement initiatives as directed.

• Consistently meets productivity and quality expectations to align performance with assigned roles and responsibilities.

• Must adhere to all of BMC’s RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

• General knowledge of healthcare terminology and CPT-ICD10 codes.

• Complete understanding of insurance is preferred.

• Requires excellent verbal communication skills, and the ability to work in a complex environment with varying points of view.

• Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail.

• Knowledge of and experience within Epic is preferred.

• Demonstrates technical proficiency within assigned Epic work queues and applicable ancillary systems, including but not limited to: ADT/Prelude/Grand Central, HB & PB Resolute.

• Demonstrates proficiency in Microsoft Suite applications, specifically Excel, Word, and Outlook.

• Displays a thorough knowledge of various sections within the work unit in order to provide assistance and back-up coverage as directed.

• Displays a deep understanding of Revenue Cycle processes and applies knowledge to meet and maintain productivity standards as outlined by Management.