Working in a fast-paced, high volume, dynamic environment, the Clinical Authorization Specialist will bring clinical expertise to the prior authorization and appeals processes and serve as a liaison and patient advocate between Dana Farber Cancer Institute and various health plans.
Reporting to the Prior Authorization Supervisor, the Clinical Authorization Specialist is responsible for managing all work related to molecular pathology, high-cost drug, and off-label drug authorizations. The Clinical Authorization Specialist is also responsible for managing denials related to front-end prior authorization, biosimilar drugs, pharmacy-benefit exclusion drugs, and claims.
With direct oversight, the Clinical Authorization Specialist:
- Manages approval process for clinically complex cases:
- Discusses complex medical necessity cases in all aspects of the prior authorization work (on-label drug, off-label drug, laboratory testing, and others as assigned) with attending physicians.
- Understands clinically complex medical situations and communicates appropriate medical information to the insurer.
- Completes medical literature searches and/or coordinates appropriate provider-to-payer medical director discussions.
- Collaborates with attending physicians on treatment alternatives when medical necessity coverage denials cannot be overturned.
- Appropriately escalates complex cases to Drug Authorization Supervisor or Manager of Prior Authorizations.
- Monitors email communication to the Drug Authorization Mailbox and distribution lists:
- Triages work to the appropriate staff member or assists with finding the correct team for the inquiry.
- Answers complex payer-related questions.
- Coordinates with clinicians and other staff members to help resolve more complex inquiries.
- Assists Drug Authorization Specialists with medical necessity denial review:
- Ensures that all necessary medical information was provided to the third-party payer.
- If necessary, helps clinical team understand denial and coordinates appeal process.
- Creates cost estimates for waivers.
- Root causes claim denials, reprocesses, and submits claim appeals.
- Creates drug cost estimates for both on-label and off-label waivers and ABN's. Communicates cost estimates to the clinical team and provides guidance on available assistance programs.
- Completes Molecular Pathology requests with the goal of resolving coverage issues prior to performing the testing.
- Review and monitor the drug authorization work queue, identifying patient treatment/therapy plans that require prior authorization.
- Serve as a clinical resource to the Revenue Integrity and Billing Compliance team.
- Performs other duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:- Knowledge of third-party payer rules and regulations highly desirable.
- Good judgment, tact, sensitivity, and the ability to function in a fast paced, highly demanding environment.
- Analytical and problem-solving skills.
- Understanding and ability to work in various computing/information systems and Microsoft Office product suite.
- Ability to mentor and educate team members, including by example.
- Ability to function independently and prioritize work within established policies.
- Ability to prioritize, meet pre-determined deadlines and work in high pressure situations.
- Ability to work with sensitive patient information and maintain confidentiality.
- Ability to work closely and effectively with colleagues across the organization including medical staff.
MINIMUM JOB QUALIFICATIONS: Minimum Education:
Bachelor's degree required. BSN preferred.
Minimum Experience:
1 year of clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred.
The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate's relevant experience, skills and qualifications.
For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA).
$83,500.00 - $95,400.00
