Prior Authorization Specialist, Neurology

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

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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

Pay Range

Grade