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Job Details

Clinical Authorization Specialist (Part-Time)

Category: Professional and Management
Malden, MA

Department: Central Referral Dept
Employment Type: Part Time
Job Type: Non-Union
Work Shift: Days
Work Days: 9:00 a.m. to 1:00 p.m. Monday through Friday
Hours/Week: 20
Date Posted: 07/18/2017
Requisition Number: hrq-76584

Job Details

  • Job Duties

    • Performs prior authorization requests for various services requested by third party insurances. Current services include but are not limited to: advanced imagining, high cost pharmaceuticals, surgical day procedures and other specialty or high cost items such as sleep studies. These requests may be telephonic, via paper, or other means such as web based. These prior authorizations are typically clinical in nature • Gathers medical information upon which to base a decision, appeal the decision by the insurance company, or educate providers on appropriate guidelines for a given service • Reviews referral/authorization requests based on medical necessity through the application of approved clinical criteria and assessment of the individual needs of member and in conjunction with the provider's request ? In preparation to speak with insurance company, reviews provider request, pertinent clinical encounters, exams and tests using CHA medical record system(s) and EMR. Receive preauthorization requests from CRO advance imaging staff through direct interaction, call transfer or fax on cases requiring clinical intervention. Speaks to insurance company's medical management department to determine if clinical information meets medical necessity criteria or requires additional medical necessity review. Notify ordering physician or rendering service provider of the preauthorization determination decision when peer to peer MD review is needed. Document the results of the clinical review and determination on the pre-certification paperwork; documentation is typically completed in Epic • Maintain confidentiality of patient and provider specific information • Maintain telephone service standards in accordance with departmental performance standards • Maintain accurate and current information for tracking and quality assurance purposes • Meets documentation standards • Thorough knowledge of a specialized or technical field such as clinical nursing knowledge in medical/surgery, advanced imagining, or chemotherapy plus the application of basic managed care theory


    • Prior experience with management of medical information, hospital information systems and other tools in patient care, particularly with Epic and Meditech systems • Prior experience in researching and assessing information governed by third party payers that impact prior authorizations for many different services, particularly in the ambulatory or surgical day care environment • General knowledge of healthcare revenue cycle including familiarity authorizations, referrals and benefit coverage as well as general reimbursement methodologies, coding, CDM, and charge capture • Solution driven experience that helps facility quality documentation, systems, and processes across several departments to support outcomes and timely transfer of information • Ability to manage and prioritize cases based on insurance company requirements and delivery of timely service to the patient • Solid analytical and computing skills including use of MSOffice, spreadsheets, and internet searches to complete research • Ability to work effectively with professionals and non- professionals in a team oriented environment, particularly in situations of high complexity and high intensity in a positive and professional manner • Motivated and self directed with a high degree of professional accountability and ability to work autonomously • Pleasant, professional, solid interpersonal skills; problem-solving orientation, good analytical skills, strong team player; self-starter, initiate assignments with minimal supervision • Excellent phone/communication skills – able to convey key concepts clearly and succinctly • Superior customer service skills to help internal customers and overall patient experience of care • Personal flexibility to perform in an ever-changing work environment


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