Team Lead, Prior Authorizations

Mass General Brigham•Somerville, MA

1d•$26 - $36•Remote

About The Position

Mass General Brigham is seeking a highly organized and experienced Prior Authorization and Referral Team Lead to oversee the daily operations of the prior authorization and referral function. This role is responsible for ensuring the timely, accurate, and compliant processing of authorization and referral requests for medical services while supporting an exceptional experience for patients, providers, and internal partners. The Team Lead will oversee workflows related to insurance eligibility verification, specialty referrals, medical necessity review, and the collection, review, submission, and documentation of required clinical and authorization information. This individual will serve as a key resource to staff and cross-functional partners, collaborating with providers, clinical teams, payers, third-party administrators, and other departments to resolve complex authorization issues and ensure services are appropriately authorized. In addition to operational oversight, this role provides leadership, mentorship, training, and support to team members. The Team Lead will use Epic and Tableau reporting tools to monitor department performance, identify workflow trends, forecast staffing needs, and support data-driven decision-making. This position will also identify opportunities for process improvement, conduct proactive and reactive audits, and help ensure compliance with payer requirements, healthcare regulations, organizational policies, and HIPAA standards. This is an excellent opportunity for a detail-oriented healthcare professional who enjoys problem-solving, leading others, working collaboratively across departments, and improving processes in a complex healthcare environment.

Requirements

High School Diploma or Equivalent required
Experience in prior authorization, medical billing, or related roles within a healthcare setting 3-5 years required

Nice To Haves

associate's degree Medical Billing and Coding preferred
associate's degree Related Field of Study preferred
Experience in a leadership or supervisory role 1-2 years preferred
Epic experience 1-2 years preferred
In-depth knowledge of prior authorization processes, payer requirements, and healthcare regulations.
Strong leadership, management, and team-building skills.
Excellent communication and interpersonal skills, with the ability to interact effectively with providers, patients, and insurance representatives.
Proficiency in electronic health records (EHR) systems and prior authorization software.
Strong analytical and problem-solving abilities, excellent attention to detail, and organizational skills.
Ability to work in a fast-paced environment.
Knowledge of prior authorization and referral workflows within a complex healthcare system.
Experience with insurance verification, medical necessity review, denials management, and appeals.
Familiarity with CPT coding and the clinical documentation required to support authorization requests.
Experience working with Epic work queues and operational reporting tools such as Tableau.
Demonstrated ability to identify process inefficiencies and implement sustainable workflow improvements.
Strong attention to detail and commitment to accuracy and compliance.
Ability to work independently while also functioning effectively as part of a collaborative team.
Demonstrated commitment to providing excellent service to patients, providers, and colleagues.

Responsibilities

Oversee the day-to-day operations of the Prior Authorization and Referral department, ensuring efficient workflows, timely processing, and adherence to organizational policies and procedures.
Lead, mentor, precept, and train team members, providing ongoing guidance and support to promote accuracy, productivity, professional development, and high-quality service.
Monitor department workflows and performance using Epic and Tableau dashboards and reporting tools, including work queue monitoring reports, to identify trends, evaluate workload, and forecast staffing needs.
Ensure prior authorization and referral requests are processed accurately and within required timeframes in accordance with payer requirements, healthcare regulations, organizational policies, and HIPAA standards.
Ensure required medical records, clinical documentation, medical necessity information, and authorization details are appropriately collected, reviewed, submitted, and documented in the EHR.
Coordinate authorization requirements for medical services, including tests, procedures, imaging, and specialty care, ensuring all required information is submitted accurately and promptly to insurance companies and other payers.
Identify and communicate authorization concerns to patients, providers, and appropriate internal stakeholders prior to scheduled admissions, procedures, or services.
Collaborate with providers, ordering clinicians, clinical departments, medical offices, payers, and third-party administrators to resolve complex authorization and referral issues.
Review and address complex authorization denials and appeals, partnering with providers, patients, and payers to gather supporting documentation and pursue appropriate resolutions.
Collaborate with ordering clinicians and other clinical partners, when needed, to ensure appropriate CPT codes and supporting clinical information are submitted for prior authorization and referral requests.
Develop, implement, and monitor process improvements designed to increase operational efficiency, improve accuracy, and reduce authorization and referral turnaround times.
Conduct proactive and reactive audits to identify compliance risks, workflow gaps, documentation issues, and opportunities for continuous improvement.
Identify opportunities to standardize processes, strengthen departmental workflows, and enhance communication and collaboration across departments.
Maintain accurate and timely documentation of authorization and referral activities in accordance with organizational, payer, regulatory, and HIPAA requirements.
Refer patients to Financial Counseling and other appropriate resources when financial assistance, insurance guidance, or additional support is needed.
Perform other duties and responsibilities as assigned.