Prior Authorization Specialist

• Complete financial clearance activities for services rendered in outpatient departments
• Monitor outcomes to ensure medical necessity and authorization requirements are met
• Provide feedback to departments on medical necessity and authorization processes
• Verify patient insurance eligibility using online tools and direct payer contact
• Identify payer medical necessity determinations before services are rendered and inform departments of failed instances
• Request additional information to rerun medical necessity checks when needed
• Determine authorization requirements and obtain payer authorization using payer-specific protocols
• Coordinate additional information from departments
• Identify and escalate issues for resolution; communicate with revenue cycle peers, leadership, and clinical stakeholders
• Document interim and final results in appropriate systems
• Complete assigned work queues and daily reports to meet productivity and quality standards
• Assist with medical necessity review and authorization for urgent or walk-in visits
• Refer patients to financial counselors for complex financial issues or inquiries
• Follow BIDMC policies, procedures, and training materials to comply with federal, state, and contractual requirements
• Identify trends and provide periodic operational, productivity, and quality reports to departments
• Perform other activities as needed to support the department