Job Title & Specialty Area: High-Cost Therapy Liaison RN

Department: Utilization Management

Location: Children's Health- Trinity Towers

Shift: Monday through Friday 8:00a to 5:00p

Job Type: Remote, but there will be an expectation to come onsite 2x a month as well as any events that will require onsite attendance

Summary:
A specialized clinical and reimbursement-focused role responsible for coordinating and managing complex, high-cost medication authorizations to support timely patient access to therapy. Leveraging advanced clinical knowledge and expertise in specialty medications, payer policies, medical necessity requirements, and FDA-approved indications, this role conducts comprehensive reviews of clinical documentation to develop and support authorization, denial, and appeal submissions.Working collaboratively with providers, pharmacists, clinical teams, payers, and manufacturers, the High-Cost Therapy Liaison RN serves as a subject matter expert on high-cost therapies and complex authorization requirements. This position applies critical thinking and nursing judgment to navigate coverage barriers, interpret evolving payer guidelines, identify approval risks, and recommend strategies to optimize authorization outcomes. The role requires a high level of strategic problem-solving abilities, attention to detail, and specialized knowledge of reimbursement processes to ensure compliant, accurate, and efficient access to high-cost and specialty medications.

Responsibilities:
* Serve as a subject matter expert on specialty and high-cost therapies by interpreting payer policies, medical necessity criteria, clinical guidelines, FDA-approved indications, and reimbursement requirements to support coverage determinations and authorization outcomes
* Review and evaluate complex clinical documentation, including medical records, treatment history, laboratory results, and diagnostic information, to support high-cost medication authorization requests
* Collaborate with physicians, pharmacists, and clinical staff to obtain and develop supporting documentation, including letters of medical necessity, treatment plans, and evidence-based medical research publications.
* Develop and maintain relationships with pharmaceutical manufacturers to ensure timely authorization and administration of medication therapies.
* Coordinate and manage prior authorizations for specialty, infusion, and other high-cost therapies across multiple payer types to ensure timely patient access to treatment and accurate payment of claims in support of organizational goals.
* Supports the coordination of payer, financial, and operational processes related to high-cost therapies to ensure appropriate access and reimbursement.
* Utilize clinical judgment and critical thinking to assess complex cases, resolve non-routine authorization challenges, and escalate issues to other stakeholders to assist with resolution as appropriate
* Manage authorization denials, reconsideration, and appeal activities by reviewing payer determinations, coordinating peer-to-peer discussions, obtaining supporting clinical documentation, and facilitating timely submissions.
* Maintain accurate and compliant documentation of authorization activities, payer communications, determinations, and appeal outcomes within designated systems.
* Maintains advanced knowledge of specialty medications, reimbursement practices, payer policies, and regulatory requirements affecting high-cost therapies.
* Develop and maintain relationships with pharmaceutical manufacturers to ensure timely authorization and administration of medication therapies.
* Acts as a preceptor and mentor for new employees, ensuring a smooth onboarding experience through education on workflows, policies, procedures, and departmental
* Maintains performance in accordance with departmental productivity and quality metrics, ensuring timely and accurate authorization processing to support continuity of care and maximize claim reimbursement.
* Educates providers and office staff on payer requirements, formulary restrictions, and authorization processes. and reimbursement considerations to improve access to therapy.

How You'll Be Successful:

WORK EXPERIENCE
* At least 2 years clinical or healthcare-related experience in acute care, ambulatory care, specialty pharmacy, infusion services, case management, utilization management, and/or population health. Required and
* At least 1 year experience in medication prior authorizations, specialty medications, high-cost therapies, reimbursement activities, or payer-related functions involving commercial, Medicare, Medicaid, and other insurance coverage determinations, denials, and appeals. Required

EDUCATION
* BSN in Nursing Essential BSN
* Masters Degree Preferred

LICENSES AND CERTIFICATIONS
* Registered Nurse-1N-RN Essential Current license to practice professional nursing in the State of Texas - Time Frame: Upon Hire

Holistic Benefits - How We'll Care for You:
• Employee portion of medical plan premiums are covered after 3 years.
• 4%-10% employee savings plan match based on tenure
• Paid Parental Leave (up to 12 weeks)
• Caregiver Leave
• Adoption and surrogacy reimbursement