Massachusetts General Hospital
Prior Authorization Specialist, Hybrid
Massachusetts General Hospital, Boston, Massachusetts, us, 02298
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. 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.).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.Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits.Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and/or guidelines.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.Ability to identify incomplete clinical documentation that is needed to obtain approval for services.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.Monitors pending cases to ensure that approvals are obtained prior to admission or visit.Advises uninsured and underinsured patients regarding available programs.Reviews and follows-up on all emergency and unscreened admissions as soon as possible.Follows all cases throughout the duration of the admission, working with Utilization Review (UR) Department.Reviews RTE eligibility system in EPIC throughout admission for any Payer changes or discrepancies.Reviews cases daily for patient class changes.Scans authorization related information into Epic Media Manager and documents notes in accordance with QA Metrics.Stays current with Payer changes in authorization requirements and restrictions.Maintains a daily workflow of Ontrac work lists and keeps Epic auth/cert fields and notes updated.Adheres to Customer Service Standards (Service Excellence) by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors, and other staff members.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.Knowledge of the hospital information system with emphasis on registration and insurance verification.Demonstrated excellent customer service abilities.Proficiency in oral and written communication.Heightened ability to effectively interact with various levels of the organization.Ability to work independently, with minimal supervision.Able to identify when something needs to be escalated to Senior Management.Commitment to collaborating within functional team.Adeptness in assessing and solving problems, excellent organizational skills.Possess a continuous and nimble learning mindset.Demonstrated ability to enact good judgment, tact, sensitivity.EDUCATION:
HS Diploma or GED equivalent required.Bachelor's degree preferred.EXPERIENCE:
Experience with, knowledge of, or desire to learn about elements of exceptional patient experience environments.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 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 metric.MGH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
#J-18808-Ljbffr
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.).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.Contacts insurance companies, managed care plans, outside agencies, and intermediaries to verify insurance coverage and benefits.Determines eligibility for admission/treatment in compliance with hospital policy, utilization review criteria, and State and Federal regulations and/or guidelines.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.Ability to identify incomplete clinical documentation that is needed to obtain approval for services.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.Monitors pending cases to ensure that approvals are obtained prior to admission or visit.Advises uninsured and underinsured patients regarding available programs.Reviews and follows-up on all emergency and unscreened admissions as soon as possible.Follows all cases throughout the duration of the admission, working with Utilization Review (UR) Department.Reviews RTE eligibility system in EPIC throughout admission for any Payer changes or discrepancies.Reviews cases daily for patient class changes.Scans authorization related information into Epic Media Manager and documents notes in accordance with QA Metrics.Stays current with Payer changes in authorization requirements and restrictions.Maintains a daily workflow of Ontrac work lists and keeps Epic auth/cert fields and notes updated.Adheres to Customer Service Standards (Service Excellence) by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors, and other staff members.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.Knowledge of the hospital information system with emphasis on registration and insurance verification.Demonstrated excellent customer service abilities.Proficiency in oral and written communication.Heightened ability to effectively interact with various levels of the organization.Ability to work independently, with minimal supervision.Able to identify when something needs to be escalated to Senior Management.Commitment to collaborating within functional team.Adeptness in assessing and solving problems, excellent organizational skills.Possess a continuous and nimble learning mindset.Demonstrated ability to enact good judgment, tact, sensitivity.EDUCATION:
HS Diploma or GED equivalent required.Bachelor's degree preferred.EXPERIENCE:
Experience with, knowledge of, or desire to learn about elements of exceptional patient experience environments.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 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 metric.MGH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
#J-18808-Ljbffr