Req#: R13374
Category(s): Administrative Support, Customer Service
Full Time / Part Time: Full-Time
Shift: First

Summary: 

The Prior Authorization Specialist is responsible for obtaining authorizations to ensure reimbursment for specialty services and testing provided throughout Baystate Health. Demonstrates excellent communication, strong customer service, critical thinking, and problem solving skills. Completes all appropriate forms, applications, and information for departmental statistics. Accurately manages the referral and authorization process. Able to secure authorization and necessary documentation to ensure patient care is not impacted and meets time-sensitive requests. Is pro-active in troubleshooting instances which could result in great financial loss. Demonstrates excellent customer service skills and works in a positive manner for collaboration and clear communication between providers, staff, insurers, and families. The specialist works closely with the appropriate clinical team members for information gathering and patient data. Participates in departmental meetings and meets all timelines for reports. Meets turnaround expectations for majority of prior authorization approvals.

Job Responsibilities: 

1) Processes all referrals and authorizations received. Completes prior authorizations and referrals as required for services and testing. Collaborates with clinical team members, physician offices and agencies to ensure than an accurate and timely referral/authorization is processed and documented in accordance with department guidelines.

2) Monitors and works denial and no referral reports to obtain required prior authorizations and referrals. Process appeals for denied claims.

3) Manages and maintains the Electronic Referral Tracking Report for accuracy of information, urgency, and othe designated criteria.

4) Acts as a resource to all internal and external customers, offering guidance and support for referral and authorization related questions and referral/authorization processing problems. Ensures patients receive timely and courteous communications.

5) Informs referring providers when a requested service authorization request is denied.

6) Maintains statistical information and reports as directed.

7) Stays current with the insurance authorization requirements by utilizing the resource library of payor benefit-specific information and provider contact information.

8) Enters referrals and authorizations in to the system per standardized practice protocols and provides feedback to ordering provider and parent/patient in a timely manner.

9) Documents and provides updates in the patient's medical record, the status of the referral and/or authorization.

10) Communicates and provides feedback to providers and staff regarding changes, trends, and processes.

Required Work Experience: 

1) 1-3 years of medical insurance knowledge

Preferred Work Experience: 

1) Bilingual (English/Spanish) preferred

Skills and Competencies: 

1) Knowledge of medical terminology preferred, Microsoft Office, Word, and Excel

2)  Experience with CIS inbox and EMR

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

GED or HiSET (Required)

Certifications:

Equal Employment Opportunity Employer

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