Prior Authorization Specialist
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AI 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
SummaryReviews and processes prior authorization and referral requests for medical services in accordance with organizational policies and payer requirements. Ensures insurance eligibility, coordination of benefits, site‑of‑care compliance, and medical necessity by gathering and submitting complete medical documentation in alignment with HIPAA standards. Accurately documents authorization outcomes and all payer communications in the electronic health record.
Essential Functions
-Work as part of a group to secure insurance authorizations in an appropriate timeframe. Collects and accurately enters information required by third parties for precertification for procedures, tests and imaging.
-When unclear, collaborates with ordering clinicians to ensure the proper CPT codes are submitted for prior authorization or referrals.
-Refer patients to financial counseling, as appropriate.
-Inform patient of authorization concerns prior to admission/procedure, coordinating with appropriate parties to facilitate authorization as appropriate, collaborating with other departments/offices to resolve complex authorization issues.
-Update authorization status in system and complete workflow.
-Respond to internal and external inquiries regarding authorization decisions and provide explanations as needed.
Qualifications
Education
- High School Diploma or Equivalent required
Experience
- Medical authorization or related field experience 1-2 years preferred
- 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.
Additional Job Details (if applicable)
Remote Model Requirements
- Remote
- M-F Eastern business hours required
- Employees must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$ - $28.30/Hourly
Grade
3
EEO Statement:
Mass General Brigham Competency Framework
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.
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