Current jobs related to Prior Authorization Specialist, Hybrid - Boston, Massachusetts - Massachusetts General Hospital(MGH)

  • Medication Authorization Specialist

    4 weeks ago

    Boston, Massachusetts, United States Massachusetts General Hospital Full time

    Job SummaryMGH Gastroenterology is seeking a highly skilled Medication Prior Authorization Specialist to join our team. As a Medication Prior Authorization Specialist, you will be responsible for obtaining all medication prior authorizations, downloading PA requests, and entering them into CoverMyMeds. You will also be responsible for tracking patient and...

  • Medication Authorization Specialist

    1 month ago

    Boston, Massachusetts, United States Massachusetts General Hospital(MGH) Full time

    Job Title: Medication Authorization CoordinatorMGH Gastroenterology is seeking a highly skilled Medication Authorization Coordinator to join our team.Job SummaryThe Medication Authorization Coordinator is responsible for obtaining all medication prior authorizations, ensuring seamless communication with providers and office staff, and maintaining accurate...

  • Radiology Billing Specialist

    2 weeks ago

    Boston, Massachusetts, United States Brigham and Women's Hospital Full time

    Job Summary:The Brigham and Women's Hospital is seeking a skilled Radiology Billing Specialist to join our team. As a key member of our Radiology department, you will be responsible for ensuring accurate and timely billing for diagnostic imaging services. Your expertise in billing processes, third-party insurance, and prior authorization requirements will be...

  • Medication Support Specialist

    2 weeks ago

    Boston, Massachusetts, United States Brigham & Women's Hospital(BWH) Full time

    Job SummaryWe are seeking a highly skilled and detail-oriented Medication Support Specialist to join our team at Brigham and Women's Hospital (BWH). As a Medication Support Specialist, you will play a critical role in supporting our primary care department by assisting with patient medication management, receiving and reviewing medication renewal requests,...

  • Housing Placement Specialist

    2 weeks ago

    Boston, Massachusetts, United States FamilyAid Full time

    Job Title: Housing Placement SpecialistFamilyAid is a leading provider of solutions to family homelessness, empowering parents and caregivers to secure and sustain housing and build foundations for their children's futures.We prevent family homelessness whenever possible, reduce harm if homelessness can't be avoided, and provide wraparound supports that...

  • Care Transition Specialist II

    1 week ago

    Boston, Massachusetts, United States Brigham & Women's Hospital(BWH) Full time

    Care Transition Specialist II Job DescriptionThe Care Transition Specialist II works collaboratively with the Care Coordination team to complete administrative responsibilities related to care progression and care transitions along the continuum of care.They work closely with nurse care coordinators, social workers, physicians, and other care team members to...

  • Orthopedic Care Specialist

    1 week ago

    Boston, Massachusetts, United States Tidewater Orthopedics Full time

    Job Summary:The Orthopedic Care Specialist will work closely with assigned providers to support and enhance the patient's orthopedic visit. This role will assist with DME and Casting duties, while also educating patients on injury prevention, rehabilitation, and wellness.Key Responsibilities:Support assigned provider clinic by compiling patient data prior to...

  • Embedded C Software Engineer for Hybrid Work Schedule

    1 week ago

    Boston, Massachusetts, United States Motion Recruitment Full time

    Our cutting-edge technology client in Boston, MA, is seeking an experienced Embedded C developer for a contract role with a hybrid work schedule.As an engineer, you will lead efforts in designing, developing, and optimizing embedded software for advanced microcontroller-based systems.You will collaborate with a talented engineering team and have the...

  • Senior HVAC Engineer Science and Technology- Hybrid-Boston

    1 week ago

    Boston, Massachusetts, United States RG Vanderweil Full time

    About UsVanderweil Engineers is a top-ranked national full-service engineering firm specializing in MEP/FP and technology services. We work in multiple sectors, including Science & Technology, Mission Critical, Academic, Healthcare, and Commercial buildings.We are proud to be one of the leading independently owned engineering firms in the country,...

  • Care Transition Specialist II

    2 weeks ago

    Boston, Massachusetts, United States Mass General Brigham Full time

    Care Transition Specialist II Job DescriptionThe Care Transition Specialist II plays a vital role in ensuring seamless transitions for patients from hospital to post-acute care settings. This position requires strong administrative skills, excellent communication, and a deep understanding of healthcare regulations.Key Responsibilities:Provide direct...

  • Care Transition Specialist II

    3 weeks ago

    Boston, Massachusetts, United States Brigham & Women's Hospital(BWH) Full time

    Care Transition Specialist II Job DescriptionBrigham and Women's Hospital (BWH) is seeking a highly skilled Care Transition Specialist II to join our team. As a key member of our care coordination team, you will play a vital role in ensuring seamless transitions of care for our patients.Key Responsibilities:Provide administrative support to the care team,...

  • Construction Robotics Specialist

    2 weeks ago

    Boston, Massachusetts, United States Lightyx Inc Full time

    Job Title: Construction Robotics SpecialistLightYX is a cutting-edge deep-tech startup revolutionizing the construction industry. Our flagship product, the LightYX BeamerOneTM, represents a paradigm shift in construction methodologies. This advanced robotic layout system accurately projects digital plans onto construction surfaces, enabling construction...

  • Client Support Specialist

    2 months ago

    Boston, Massachusetts, United States Quipt Home Medical Full time

    Job OverviewQuipt Home Medical is a swiftly expanding frontrunner in delivering clinical respiratory apparatus and services within the durable medical equipment sector. We are in search of motivated individuals to advance with us. Position: Client Support Specialist Reports To: Branch Manager/CSR Director Position Summary:As a Client Support Specialist, you...

  • Medication Support Coordinator

    2 weeks ago

    Boston, Massachusetts, United States Brigham and Women's Hospital Full time

    Job SummaryWe are seeking a highly skilled and detail-oriented Medication Support Coordinator to join our team at Brigham and Women's Hospital. As a key member of our Primary Care department, you will play a vital role in supporting patient medication management and ensuring seamless communication between healthcare providers and patients.Key...

  • Link Building Specialist

    1 week ago

    Boston, Massachusetts, United States beBee Full time $1,000 - $20,000 per month

    Location: RemoteContract Type: FreelanceJob Overview:At bebee.com, an innovative platform focused on professional networking and knowledge sharing, we are searching for a freelance Link Building Specialist who will play a crucial role in enhancing our SEO strategy and boosting our online presence.Key Duties:Formulate and execute impactful link building...

  • Cloud Infrastructure Specialist

    2 weeks ago

    Boston, Massachusetts, United States Franklin Fitch Full time

    Cloud Infrastructure SpecialistAt Franklin Fitch, we are seeking a skilled Cloud Infrastructure Specialist to join our team. As a key member of our infrastructure team, you will be responsible for designing, implementing, and maintaining our hybrid cloud environment. Your expertise in Windows Server, Office365, VMware, Citrix, and storage solutions will be...

  • Medical Billing Specialist II

    1 month ago

    Boston, Massachusetts, United States Exact Sciences Full time

    Job Title: Medical Billing Specialist IIExact Sciences is seeking a highly skilled Medical Billing Specialist II to join our team. As a Medical Billing Specialist II, you will play a critical role in ensuring the accurate and timely filing of insurance claims for Exact Sciences.Key Responsibilities:Determine initial and ongoing patient insurance eligibility...

  • Senior Investment Operations Specialist

    1 week ago

    Boston, Massachusetts, United States ProPivotal Staffing Full time

    Senior Investment Operations SpecialistProPivotal Staffing is seeking a skilled Senior Investment Operations Specialist to support the Private Investment Team in Boston. The ideal candidate will have a minimum of 3 years of professional experience in the Investment Industry/Asset Management sector, with a focus on private investment operations and private...

  • Procurement Specialist

    1 week ago

    Boston, Massachusetts, United States Amentum Full time

    The Procurement Specialist role at Amentum is a critical position that requires a skilled professional to manage the procurement of materials, components, supplies, and services for the company. The ideal candidate will have a strong understanding of procurement procedures, contract requirements, and federal acquisition regulations.The Procurement Specialist...

  • Cardio-Oncology Echocardiography Specialist

    2 months ago

    Boston, Massachusetts, United States Tufts Medicine Full time

    About the RoleTufts Medicine is seeking a highly skilled Non-Invasive Cardiologist with expertise in Cardio-Oncology and Echocardiography to join our dynamic team at the CardioVascular Center.Key ResponsibilitiesProvide exceptional patient care through out-patient and in-patient clinical services, with a focus on Cardio-Oncology, General Cardiology, and...

Prior Authorization Specialist, Hybrid

3 months ago

Boston, Massachusetts, United States Massachusetts General Hospital(MGH) Full time

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.). 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
  • 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.
  • 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.
Qualifications
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 enviornment.

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, 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 metric

EEO Statement
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.