Prior Authorization Specialist, Neurology
Job Location:
Boston, NH - USA
Weekly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
The Prior Authorization Specialist II supports the Department of Neurologys revenue cycle operations with a primary focus on prior authorizations referrals insurance eligibility verification and resolution of authorization-related denials. Working closely with providers clinical teams and revenue cycle staff this role ensures timely and accurate processing of payer requirements to support patient care and reimbursement. The position is responsible for obtaining and managing authorizations working payer denials and appeals related to authorization requirements and helping remove barriers to care and reimbursement. The role requires strong attention to detail effective communication skills and the ability to navigate complex insurance and authorization processes while maintaining accurate documentation and a high level of customer service.Qualifications
Education
High School Diploma or Equivalent required
Can this role accept experience in lieu of a degree No
Experience
Experience in medical authorization or a related field 2-3 years required and Epic experience 0-1 year preferred
Knowledge Skills and Abilities
- Excellent attention to detail and organizational skills.
- Strong communication and interpersonal skills.
- Knowledge of medical terminology and medical insurance benefits including a complete understanding of the coordination of benefits.
- Familiarity with computer systems and databases.
- Ability to work independently and as part of a team.
- Ability to work in a fast-paced environment.
- Obtain insurance authorizations prior to initiation of patient services.
- Ensure all required insurance referrals are received complete and accurately documented.
- Perform demographic and insurance eligibility checks in Epic NEHEN and other payer systems; update or escalate discrepancies.
- Facilitate referral and prior authorization requests with payers and specialty pharmacies via phone fax and payer portals.
- Collect review and submit clinical documentation required to support medical necessity and payer authorization requirements.
- Collaborate with providers and clinical staff to obtain information necessary to support authorization requests reconsiderations and appeals.
- Independently manage complex high-cost high-risk or time-sensitive authorization requests and escalate issues as appropriate.
- Maintain accurate and timely documentation of all authorization and referral activity in Epic.
- Maintain working knowledge of payer requirements coverage guidelines and eligibility rules across managed care organizations.
- Monitor and take action on work queues related to authorizations referrals denials and appeals ensuring timely follow-up and resolution.
- Partner with the Lead Managed Care Coordinator revenue cycle and billing teams to resolve authorization- and referral-related denials and support reconsiderations reprocessing and appeals.
- Assist in identifying and escalating payer or patient-related issues that may impact reimbursement.
- Identify trends in authorization denials or delays and communicate opportunities for improvement to leadership.
- Follow established department workflows and managed care processes.
- Scan provider schedules for non-contracted plans and escalate issues to Practice Administrators or the Lead Managed Care Coordinator.
- Maintain up-to-date tracking mechanisms and records of authorization referral denial and appeal activities.
- Participate in Department Appointment Review (DAR) follow-up activities where applicable.
- Review payer-specific requirements site-of-care guidelines and coverage limitations and escalate concerns as appropriate.
- Collaborate with team members to review adopt and maintain workflows and best practices.
- Serve as backup to other Prior Authorization Specialists and administrative staff as needed.
- Work closely with Practice Administrators registration teams billing staff providers and clinical teams to ensure accurate information flow.
- Communicate clearly with patients regarding authorization requirements status updates insurance-related barriers to care and next steps.
- Serve as a resource for authorization referral eligibility and denial-related questions and escalate complex issues to the Lead Managed Care Coordinator.
- Serve as backup to other staff as needed.
- Identify workflow inefficiencies and communicate opportunities for improvement to the Lead and leadership team.
- Support implementation of standardized workflows tools and best practices across sites.
- Maintain working knowledge of payer policies authorization requirements and system updates.
- Identify authorization denial patterns and recommend workflow improvements to reduce delays and improve approval rates.
- Support training and onboarding of new staff as directed by the Lead Managed Care Coordinator.
- Adhere to and help maintain departmental policies procedures and workflow documentation.
- Attend departmental and practice meetings as required.
- Ensure compliance with all hospital state and federal regulations including HIPAA and Joint Commission standards.
- Perform other duties as assigned.
Additional Job Details (if applicable)
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4EEO Statement:
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
IC
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
