Provides leadership, efficient, effective oversight of day-to-day activities and teams in the prior authorization and referrals space. In partnership with key stakeholders, the Manager, Prior Authorization and Referrals, contributes and supports enterprise prior authorization and referral strategy, and continuously works to improve people, process, and technology across the function. The Manager provides leadership and direct supervisory support of team members.
The prior authorization and referrals team is responsible for insurance validation & verification, capture of insurance referrals and prior authorizations, updating patient data in Epic, and work queue management functions. Through their leadership and oversight, the Manager, Prior Authorization and Referrals will work to ensure that patients receive a smooth and efficient experience while collecting accurate insurance and related information while facilitating the necessary administrative procedures to ensure a clean claim with complete data. Provides insight and incorporates denials prevention and payer requirements into workflow to minimize revenue leakage. For the Manager, Prior Authorization and Referrals in the Healthcare At Home division, this role also works closely with the Patient Financial Services team on denial appeals and write off decisions.
Education
Bachelor's degree preferred with discipline inHealthcare Administration, Management, Finance, Business Administration, or related field.
Work Experience
Skills/Abilities/Competencies:
Demonstrates competency and leadership experience in a large, complex organization with multiple locations. Strong operational management and process/technology optimization skills. Excellent personnel management and organizational management skills - including written and oral communication, relationship management, customer service, and organization. Comprehensive knowledge of patient registration contractual terms and requirements, health insurance practices, and industry standards. Familiarity with various call center technologies, including but limited to; workforce management, ACD call routing and reporting and quality monitoring. Communicate and operate effectively within and between system functions. Undertake an enterprise-wide perspective with respect to their role. Manage upwards, elevating key risks and opportunity areas to Patient Access & Experience. Build consensus and lead change within a large matrix organization with multiple stakeholder groups. Exercise judgement in dealing with sensitive, confidential information
Leadership Impact & Problem Solving
Develops, motivates and retains front-line team members. Oversees the recruiting, hiring, orientation and integration of new team members into the team. Acts as a role model demonstrating commitment to Mass General Brigham's goals, philosophies, values and vision. Empowers all members of the team to make appropriate front-line decisions to resolve issues for customers at point of contact. Sets high standards of professional behavior, corporate responsibility and integrity. Supports team members in activities that promote personal and professional development Aligns prior authorization and referral deployment with Mass General Brigham's enterprise strategy, standardizing processes across all enterprise facilities. Drives focus, efficiency, and role clarity across teams focused on prior authorizations and referrals, patient satisfaction, work queues and call-center activities. Foresees and mitigates any significantrisks in the work (Ex.denials, delays, work queue backlog, Medicaid conversions).
Consistently monitors progress and provides feedback on team member performance as well as service level targets. Ensures the timely administration of coaching and corrective action for less than acceptable performance by staff members. Ensures consistent application of departmental and health system policies and procedures. Completes performance appraisals for direct reports in a timely manner, and works with team members to set achievable performance and development goals.
Identifies system and operational problems through analysis of current processes. Recommends solutions and improvements. Embraces change and articulates the opportunities changes and growth bring to the team.
Financial Performance
Operational Performance
Monitors and manages productivity relative to teamwork queues to minimize denials, DNFB and Claim errors. Analyzes trends and root causes and solves complex operational issues (i.e., raised customer calls, identifies optimizations). Adjudicates and supports efficient and effective operational policies, standard processes, and technologies. Facilitates projects and conversations with MGB departments and stakeholders to share and develop standard processes. Recommends and engages with third party vendors where reason for performance exists. Oversees staff volume management, flexing resources across work queues based on volume demands.
Key Interactions
Patient Access and Experience Team | Collaborate with department leadership, to help influence PA&E strategy development. Health Care at Home (if applicable) | Partners with Health Care at Home leadership to ensure alignment with organizational goals Ambulatory and Hospital Operations Management| Partners with MGB leaders at sites and in ambulatory to ensure seamless patient experience and denial prevention Payer Services Team | Assist Payer Services with identified payer issues Denials Prevention Team | review denial prevention outcomes and strategies and implement process improvements
Decision Rights Accountable
Responsible
Identify and Monitor Patient Access & Experience Key Performance Indicators (within respective team). Prioritize Patient Access & Experience Resources (within respective team). Manage day to day operations of prior authorization and referrals team.
Consulted
Define Patient Access & Experience Goals. Define Policies and Practices for the Patient Access & Experience Team. Develop Revenue Cycle Operational Budgets.
Informed
Other duties and responsibilities as assigned.
Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.
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Mass General Brigham (Enterprise Services)
May 07, 2025