Prior Authorization Specialist

Mass General Brigham•Somerville, MA

2d•Remote

About The Position

Reviews 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 payer communications in the electronic health record. The role works with clinicians, patients, and other departments to obtain authorizations on time, address concerns, resolve complex authorization issues, and communicate authorization decisions. This is a remote role with a required Monday–Friday, 8:30 a.m.–5:00 p.m. EST schedule. A quiet, secure, stable, HIPAA-compliant workstation is required.

Requirements

High school diploma or equivalent.
Excellent attention to detail and organizational skills.
Strong communication and interpersonal skills.
Knowledge of medical terminology and medical insurance benefits, including 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.
Availability to work Monday–Friday, 8:30 a.m.–5:00 p.m. EST for the remote role.
Ability to use a quiet, secure, stable, HIPAA-compliant workstation.

Nice To Haves

1–2 years of medical authorization or related field experience preferred.
0–1 year of Epic experience 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 to ensure the correct CPT codes are submitted for prior authorization or referrals when clarification is needed.
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 regarding authorization decisions and provide explanations as needed.