Role Description The Prior Auth specialist would be responsible for managing end-to-end prior authorizations, including: - Reviewing clinical documentation - Identifying the correct ICD and CPT codes - Submitting requests through payer portals - Tracking pending cases - Following up proactively - Handling denials and appeals when needed - Coordinating closely with schedulers and providers to prevent delays in care Qualifications - Minimal coding experience (mostly submission) - Experience reviewing clinical documentation for completeness and accuracy - Experience submitting authorizations through payer portals and following up proactively - Ability to manage pending cases, track metrics, and stay highly organized - Experience handling denials and preparing appeals with supporting documentation

• Obtain prior authorizations for facility and professional charges following departmental protocols. • Submit CPT and HCPCS codes and medical records to insurers to expedite authorizations. • Verify patient demographics and medical details, ensuring HIPAA compliance. • Review and confirm all supporting documents and collaborate with necessary stakeholders. • Prioritize authorization requests and ensure the accuracy of CPT and ICD-10 codes. • Maintain intranet resources related to payer requirements for prior authorizations. • Notify patients or clinics if authorization is not secured before service dates. • Handle retro authorizations, resolve denials, and manage appeals as needed. • Track all actions and update patient accounts accurately. • Communicate issues like billing concerns, backlogs, and documentation needs to leadership. • Adapt to changing circumstances to support patient flow. • Maintain professionalism, integrity, and confidentiality in all interactions.

• Responsible for screening prior-authorization and coordination of specialized services requests in the medical care management program, including a broad range of requests for inpatient, outpatient and ancillary services. • Adheres to policies and procedures in order to comply with performance and compliance standards and to ensure cost effective and appropriate healthcare delivery. • Maintains current knowledge of network resources for referral and linkage to member’s and provider’s needs. • Authorizes certain specified services, under the supervision of the manager, according to departmental guidelines. • Per standard workflows, forwards specified requests to the clinician for review and processing. • Answers ACD line calls from providers and other departments and redirects, as needed. • Coordinates all financial clearance activities by navigating all pre-registration (to include acquiring or validating patient demographic, insurance, and other required elements along with insurance verification activities), obtaining referral authorization, or precertification number(s). • Ensures timely access to care while maximizing BMC hospital reimbursement. • Supports Prior Authorization Clinicians. • Answers ACD line calls, verifies member eligibility and enters into CCMS or Facets the information necessary to complete the caller’s request. • Identifies and informs callers of network providers, services, and available member benefits.

• Responsible for screening prior-authorization and coordination of specialized services requests • Adheres to policies and procedures to comply with performance and compliance standards • Authorizes specified services under supervision according to departmental guidelines • Forwards specified requests to clinicians for review and processing • Answers ACD line calls from providers and departments and redirects as needed • Coordinates financial clearance activities by navigating pre-registration, obtaining referral authorizations • Maintains current knowledge of network resources for referrals and member needs • Collaborates with stakeholders in the financial clearance process