Prior Authorization Specialist

Mass General Brigham•Somerville, MA

1d•$28•Remote

About The Position

The Prior Authorization Specialist reviews and processes prior authorization and referral requests for medical services in accordance with organizational policies and payer requirements. The role 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. It also accurately documents authorization outcomes and payer communications in the electronic health record. This position does not require patient care.

Requirements

High school diploma or equivalent required.
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 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.

Nice To Haves

Medical authorization or related field experience; 1–2 years preferred.
Epic experience; 0–1 year preferred.

Responsibilities

Work as part of a group to secure insurance authorizations within an appropriate timeframe.
Collect and accurately enter information required by third parties for precertification of procedures, tests, and imaging.
Collaborate with ordering clinicians when needed to ensure the proper CPT codes are submitted for prior authorization or referrals.
Refer patients to financial counseling, as appropriate.
Inform patients of authorization concerns before admission or a procedure, and coordinate with appropriate parties to facilitate authorization.
Collaborate with other departments and offices to resolve complex authorization issues.
Update authorization status in the system and complete the workflow.
Respond to internal and external inquiries about authorization decisions and provide explanations as needed.
Gather and submit complete medical documentation while ensuring insurance eligibility, coordination of benefits, site-of-care compliance, and medical necessity.
Accurately document authorization outcomes and payer communications in the electronic health record.