The posting
Site: The Brigham and Women's Hospital, Inc.
Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
The Prior Authorization Specialist II supports the Department of Neurology's revenue cycle operations, with a primary focus on prior authorizations, referrals, insurance eligibility verification, and resolution of authorization-related denials. Working closely with providers, clinical teams, and revenue cycle staff, this role ensures timely and accurate processing of payer requirements to support patient care and reimbursement. The position is responsible for obtaining and managing authorizations, working payer denials and appeals related to authorization requirements, and helping remove barriers to care and reimbursement. The role requires strong attention to detail, effective communication skills, and the ability to navigate complex insurance and authorization processes while maintaining accurate documentation and a high level of customer service.
Qualifications
Education
High School Diploma or Equivalent required
Can this role accept experience in lieu of a degree? No
Experience
Experience in medical authorization or a related field 2-3 years required and Epic experience 0-1 year preferred
Knowledge, Skills and Abilities
- 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 the 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.
Authorization, Referral, and Eligibility Management
- Obtain insurance authorizations prior to initiation of patient services.
- Ensure all required insurance referrals are received, complete, and accurately documented.
- Perform demographic and insurance eligibility checks in Epic, NEHEN, and other payer systems; update or escalate discrepancies.
- Facilitate referral and prior authorization requests with payers and specialty pharmacies via phone, fax, and payer portals.
- Collect, review, and submit clinical documentation required to support medical necessity and payer authorization requirements.
- Collaborate with providers and clinical staff to obtain information necessary to support authorization requests, reconsiderations, and appeals.
- Independently manage complex, high-cost, high-risk, or time-sensitive authorization requests and escalate issues as appropriate.
- Maintain accurate and timely documentation of all authorization and referral activity in Epic.
Authorization Denial & Reimbursement Support
- Maintain working knowledge of payer requirements, coverage guidelines, and eligibility rules across managed care organizations.
- Monitor and take action on work queues related to authorizations, referrals, denials, and appeals, ensuring timely follow-up and resolution.
- Partner with the Lead Managed Care Coordinator, revenue cycle, and billing teams to resolve authorization- and referral-related denials and support reconsiderations, reprocessing, and appeals.
- Assist in identifying and escalating payer or patient-related issues that may impact reimbursement.
- Identify trends in authorization denials or delays and communicate opportunities for improvement to leadership.
Operational Workflow Support
- Follow established department workflows and managed care processes.
- Scan provider schedules for non-contracted plans and escalate issues to Practice Administrators or the Lead Managed Care Coordinator.
- Maintain up-to-date tracking mechanisms and records of authorization, referral, denial, and appeal activities.
- Participate in Department Appointment Review (DAR) follow-up activities where applicable.
- Review payer-specific requirements, site-of-care guidelines, and coverage limitations and escalate concerns as appropriate.
- Collaborate with team members to review, adopt, and maintain workflows and best practices.
- Serve as backup to other Prior Authorization Specialists and administrative staff as needed.
Collaboration & Communication
- Work closely with Practice Administrators, registration teams, billing staff, providers, and clinical teams to ensure accurate information flow.
- Communicate clearly with patients regarding authorization requirements, status updates, insurance-related barriers to care, and next steps.
- Serve as a resource for authorization, referral, eligibility, and denial-related questions and escalate complex issues to the Lead Managed Care Coordinator.
- Serve as backup to other staff as needed.
Process Improvement & Quality
- Identify workflow inefficiencies and communicate opportunities for improvement to the Lead and leadership team.
- Support implementation of standardized workflows, tools, and best practices across sites.
- Maintain working knowledge of payer policies, authorization requirements, and system updates.
- Identify authorization denial patterns and recommend workflow improvements to reduce delays and improve approval rates.
Training & Documentation Support
- Support training and onboarding of new staff as directed by the Lead Managed Care Coordinator.
- Adhere to and help maintain departmental policies, procedures, and workflow documentation.
Other Duties
- Attend departmental and practice meetings as required.
- Ensure compliance with all hospital, state, and federal regulations, including HIPAA and Joint Commission standards.
- Perform other duties as assigned.
Additional Job Details (if applicable)
Remote Type
Hybrid
Work Location
1620 Tremont Street
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
- /
Grade
4
At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
EEO Statement:
2200 The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
