Prior Authorization Manager

GENERAL SUMMARY/ OVERVIEW STATEMENT: Summarize the nature and level of work performed.

The Manager of MGB BWH/BWF Prior Authorization Team reports to the Patient Access Services Executive Director and is responsible for the daily operations of the Prior Authorization Team. This position includes responsibilities related to the financial management, personnel management, policies and procedures, and compliance requirements for both MGB Brigham and Women's and Faulkner hospitals. This position is responsible for mitigating financial risk to these MGB hospitals which includes preventing denials and minimizing write offs for both hospitals. This manager will work closely with the Prior Authorization Senior Manager and Patient Access Services Executive Director and oversee approximately 10 employees and 1 Team Lead. The Prior Authorization Manager must have sufficient knowledge to cover for Prior Authorization Senior Manager related to sickness, leaves, and vacations which includes an additional 20 employees, one Supervisor, and two Team Leads. The job responsibilities also include quality, safety, efficiency, patient satisfaction, cost management, staff satisfaction, growth, and revenue optimization for over $2.5 billion in Net Patient Service Revenue annually. The Prior Authorization Manager also collaborates with MGB leaders across all the hospitals to optimize the efficiency and effectiveness of all these processes and implement standardization and best practices across the system. The Manager performs all these functions in a manner that complies with the standards established by Hospital Administration, Medical Staff, and outside regulatory and accreditation agencies. This position demands a high level of responsibility with minimal supervision.

Leadership & Personnel Management

• Provides the proper leadership, supervision, environment, and reporting structure to assure productivity, performance, and well-being of Prior Authorization Specialists.

• Works with the Executive Director on strategies to create and maintain exceptional employee experience and high-performing teamwork.

• Participates in other enterprise strategic responsibilities such as the monthly Mass General Brigham enterprise Registration/Financial Clearance Workgroup, Weekly Mass General Brigham WQ Monitoring Meeting, Mass General Brigham Management Group, Mass General Brigham Payor Operations monthly and quarterly enterprise-wide meetings, and monthly MGB Brigham and Faulkner Inpatient and Outpatient Revenue Operations Meetings.

• Oversees Team Lead and Supervisors to execute operational excellence.

• Collaborates with the Mass General Brigham and Faulkner Training Specialist to develop and implement ongoing training programs for the entire function, including new hire on-boarding and in-service training programs for staff as necessary.

• Executes personnel functions such as hiring, updating job descriptions, performance evaluations, counseling, corrective action, and terminations in accordance with the hospital's personnel policies and procedures.

• Supports Director and Managers with supervision, coaching and professional development of team members within function.

• Fosters and maintains a psychologically safe environment that encourages mentoring, productivity, loyalty, accountability, and job satisfaction.

• Ensures proper orientation of employees to their jobs, adequate supervision, and productivity monitoring

• Provides the proper supervision, environment, and reporting structure to assure productivity, performance well-being of employees in Prior Authorization Unit.

• Designs and defines jobs to implement programs and documents and keeps up-to-date job descriptions.

• Creates an environment that encourages productivity, loyalty, job satisfaction, and a positive attitude.

• Responsible for professional development of staff and develops career paths for supervisors.

• Assures adherence to the hospital's personnel policies and procedures.

Fiscal Management & Business Acumen

• Provides sound financial planning, budgeting, monitoring, and analysis to support cost-effective operations and fiscal responsibility.

• Assists the Executive Director at Mass General Brigham and Faulkner to optimize revenue which is approximately $2.5 billion NPSR

• Collaborates with leaders across Mass General Brigham hospitals to establish best practices and optimize revenue reimbursement and prevent authorization denials.

• Applies in-depth knowledge of how function integrates with other business teams and operations, both across the entity and across the Mass General Brigham enterprise.

• Generates and implements new ideas for cost reduction.

Operations

• Provides leadership, organizational structure and management for realistic long-range planning and efficient daily operations for Mass General Brigham and Faulkner Prior Authorization and collaborates with Patient Financial Services, Denials and Appeals and Outsource Vendors for Prior Authorization.

• Establishes departmental goals and objectives and updates them annually and/or as needed.

• Develops, documents and updates policies and procedures of the department.

• Supports Supervisor and Team Leads in interpretation of hospital and department policies and procedures.

• Conducts regular staff meetings to coordinate the activities of the Prior Auth Team for purpose of education, payor updates, issue identification and resolution, and for employee suggestions to improve departmental performance.

• Provides clear channels of communication, delegation, and accountability within the department for effective supervision and problem-solving.

• Makes day-to-day administrative decisions consistent with the missions of the department and the hospital and general management principles.

• Maintains regular communication with Finance Department Administration.

• Establishes clear and reasonable productivity standards for operational performance monitoring and evaluation.

• Works as a team with Managers of other departments to accomplish operational requirements of Prior Authorization to prevent denials, optimize financial clearance, maximize revenue recoveries for Mass General Brigham and Faulkner hospitals.

• Designs efficient workflow and space utilization and provides equipment to support the programs

• Designs and implements programs to enable and monitor compliance.

• Develops and implements programs to maximize reimbursement, prevent unnecessary denials, and minimize financial risk to the institution.

• Manages Epic DNB WQ's to provide prompt follow-up of accounts and maintains an acceptable level of days in receivable.

• Manages Epic Queues to ensure all cases are accounted for and followed.

• Actively manages problem accounts to ensure desired outcome.

• Proactively contacts payors when alerted to a potential denial to have them overturned and funds recovered prior to full denial.

• Ensures that team maintains documentation necessary to submit appeals on denied claims.

• Establishes programs that efficiently meet notification/precertification requirements (i.e. fax, telephone, on-line, etc.) as well as mandatory follow-up.

• Designs and implements Quality Assurance Programs targeting as goals not only accuracy and efficiency, but also high levels of patient and physician satisfaction

• Provides leadership and oversight of system enhancements, process changes, and updates to policies and procedures.

• Develops and maintains excellent working relationships, based on mutual respect, with physicians, patients and their families, and all aspects of accounts receivable from time of booking until ready to bill.

• Works in conjunction with all levels of hospital personnel in establishing and maintaining programs to meet increasing contractual demands of third-party payors.

• Actively participates on designated hospital work groups as needed.

• Identifies, investigates, and resolves system errors to prevent loss of revenue.

• Provides or assists in the front-end support on all elective, urgent, and emergent admissions.

• Serves as a facilitator for the transplant programs, and any investigative protocol and/or procedure, working with clinicians and payors to ensure that all necessary third-party requirements have been met and prior approval has been received for this group of patients.

• Works with the Executive Director on revenue enhancements and process improvement projects and facilitates the resolution of complex issues impacting compliance, revenue and daily front end processes within the Mass General Brigham and Faulkner Prior Authorization Team and Denials and Appeals Departments.

• Provides review and oversight of annual operational and financial goals and objectives including development and monitoring of key performance indicators for both quality and efficiency for Mass General Brigham and Faulkner for PA, PFS, Denials and Appeals.

• Responsible for administrative decisions consistent with the missions of the department and the hospital as well as general management principles.

• Provides regular communications to the Executive Director, Finance Department Administration and Revenue Integrity Utilization Review, Clinical areas, Compliance, Payor Operations, Central Billing Office, and Finance departments to mitigate denials and maximize revenue.

• Maintains ongoing knowledge of legislative and regulatory changes which impact hospital access care, quality of care and reimbursement.

• Performs other duties as assigned.

Program Development

• Provides direction and expertise in developing programs to support the many functions of financial clearance to ensure that the hospital complies with state and federal regulations and guidelines as well as maximizing reimbursement for services rendered.

• Collaborates with the Mass General Brigham Central Billing Office (CBO) and Payor Operations to maintain programs to meet the increasing contractual demands of third-party payors and minimize loss of revenue due to denials..

• Works with the Denials and Appeals team departmental write off policy and reviews write offs for Mass General Brigham Brigham and Faulkner hospitals.

• Partners with other Directors, collaborates across MGB for process improvement program initiatives.

• Designs and implements Quality Assurance programs targeting qualitative and quantitative goals.

• Assists the Executive Directors in the establishment of programs, policies and procedures, and resource commitments.

Information Systems

• Manages and assists in the design, development/acquisition, implementation, and evaluation of large and small scaled management information systems on behalf of Executive Director to be used as operations and/or management tools for Mass General Brigham and Faulkner PA.

• Collaborates with Patient Access Managers, Directors, and clinical teams to ensure that systems function as designed across Mass General Brigham

• Collaborates with IT and the Mass General Brigham and Faulkner Director of PA and PFS to identify system issues and determine solutions for issues to optimize accuracy and efficiency when possible.

• Establishes goals, specifications, and timeline for all assigned projects with IT and PMO teams.

• Reviews EPIC system enhancements and determines impacts for PA.

• Provides oversight and direction to all Prior Authorization Unit related to downtime procedures.

• Assists in the development and review on-going departmental training for EPIC related functionality and enhancements and operational workflow changes as needed.

Working Conditions: Describe the conditions in which the work is performed

Due to the size and complexity of the department, the pace of work is hectic and challenging, the workload may necessitate working greater than standard 40-hour week to secure the authorizations

Hospital-Wide Responsibilities

• Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by BWH/Mass General Brigham

• Follows safe practices required for the position; complies with appropriate BWH and Mass General Brigham policies and procedures.

• Fulfills any training required by BWH and/or Mass General Brigham, as appropriate.

• Brings potential matters of non-compliance to the attention of the supervisor or other appropriate hospital staff.

Other

Primary Location: USA-MA-Boston

Education

• Bachelor's degree in health care setting with administrative responsibilities including project management

Experience

• 5 years in a health care setting with administrative responsibilities.

Skills, Abilities, Competencies

• Effective, results-oriented management skills. Must possess ability to provide ongoing leadership and supervision to staff.

• Excellent communication skills both oral and written.

• Thorough knowledge of Prior Authorization policies and procedures necessary to develop programs, coordinate activities and motivate and instruct others.

• Exceptional interpersonal skills to interact effectively with all levels of staff, other departments, and patient.

• Effectively collaborate and consult as a member of interdisciplinary teams as needed.

• Strong analytical and problem-solving skills.

• Functions well in a fast paced, high demand, changing environment with demonstrated ability to balance multiple demands and priorities and meet critical deadlines.

• Independent judgment needed to deviate from standard policies, procedures, and schedule when necessary.

• Demonstrates flexibility, commitment to teamwork and a willingness to make changes to meet the needs of the department.

• Ability to separate isolated issues from trends and properly diagnose problems.

• Excellent program and project management skills, with ability to apply various tools and techniques to support changing needs of function.

• Knowledge of computers and management information systems, with the ability to provide specifications for program and project development, system enhancements and reports.

• Ability to establish and maintain strong relationships with Hospital Senior Administrative staff including VPs, other department heads, legal services, committee chairpersons, and directors of Mass General Brigham.

• Creative, self-motivated, with ability to use independent judgment needed to deviate from standard policies, procedures, and schedule, when necessary, ability to focus detailed, concentrated effort to multiple initiatives and re-establish priorities as necessary.

• Strong healthcare revenue cycle technology / systems integration experience