[Hiring] Billing Managed Care Coordinator Lead @Mass General Brigham

Role Description

Responsible for overseeing prior authorization and referral requests for medical services, including insurance eligibility verification, referrals for specialty care, medical necessity review, and compliance with payer, company, and HIPAA requirements. Reviews, compiles, submits, and documents all required medical records and authorization details in the EHR, maintaining accurate communication with payers and third-party administrators. Leads and supports a team by collaborating across departments, precepting new hires, and conducting proactive and reactive audits to ensure timely processing, compliance, and continuous process improvement.

• Oversee daily operations of the prior authorization and referral department. Lead, mentor, and train team members, ensuring efficient workflow and adherence to policies and procedures.
• Regularly review Epic and Tableau dashboards, including but not limited to work queue monitoring reports to forecast staffing needs.
• Ensure compliance with payer requirements, healthcare regulations, and facility policies in all prior authorization activities, including tests and imaging, is collected, reviewed, and submitted accurately and promptly to insurance companies and other payers.
• Inform patient of authorization concerns prior to admission/procedure, coordinating with appropriate parties to facilitate authorization as appropriate, collaborating with other departments/offices to resolve complex authorization issues.
• Develop and implement process improvements to enhance efficiency and reduce authorization turnaround times.
• Address and resolve complex authorization denials and appeals, working with providers, patients, and payers to achieve favorable outcomes.
• When unclear, collaborates with ordering clinicians to ensure the proper CPT codes are submitted for prior authorization or referrals.
• Refer patients to financial counseling, as appropriate.

Qualifications

• Education: High school diploma or equivalent is required.
• Preferred Education: Associate’s degree in related field.
• Healthcare Experience: 3–5 years required in: Prior authorization medical billing or a related healthcare role.
• Leadership/Supervisory Experience: 1–2 years preferred.
• Epic Experience: 1–2 years required.

Requirements

• 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.

Benefits

• Medical, Dental, Vision
• 403b retirement plan
• Tuition reimbursement
• Discounted MBTA pass
• And more!