Reporting to the Manager of Prior Authorization, the Prior Authorization Supervisor is responsible for managing the operational workflows and staff obtaining drug and laboratory procedure prior authorizations from third-party payers. This work will primarily address on-/off-label drugs and molecular pathology procedures provided in the outpatient hospital setting.
A key focus of the Prior Authorization Supervisor will be to apply appropriate medical knowledge to all functions of the prior authorization work. He/She will oversee and ensure staff applies appropriate medical knowledge and training. The Prior Authorization Supervisor will assist with prior authorization medical necessity inquiries, with a primary focus on drug and laboratory prior authorizations.
Prior Authorization work requires its staff to serve as liaisons between the clinical team and third-party payers. The Prior Authorization Supervisor will demonstrate a strong ability to collaborate with these key stakeholders. He/She will be required to understand and discuss clinical relevance of treatment plans with providers and complete research publications reviews independently. The Prior Authorization Supervisor will have expert knowledge of third-party payer medical policies and procedures and facilitate appropriate provider-to-payer medical director discussions. He/She will apply these skills to his/her management of the prior authorization staff.
PRIMARY DUTIES AND RESPONSIBILITIES: - Understands and values the Dana-Farber Cancer Institute mission and applies it to all prior authorization processes.
- Oversees the daily on-label drug prior authorization operations related to outpatient, clinic-infused drugs and other drug infusions within the scope of the Dana-Farber Cancer Institute Access Management Department.
- Assists staff with complicated clinical or administrative on-label drug cases with the goal of resolving the prior authorization issue before rendering the service.
- Oversees clinical staff members responsible for off-label chemotherapy regimen prior authorization requests. Works closely with pharmacists, clinicians, and other access management teams, to obtain appropriate financial clearance prior to treatment. Understands and meets treatment deadlines appropriately.
- Assists clinical staff with complicated clinical or administrative off-label chemotherapy regimen requests with the goal of resolving coverage issues. Escalates complicated administrative cases to Manager of Prior Authorization or Access Management Director.
- Assists in the design and implementation of new molecular pathology prior authorization workflows.
- Oversees the daily molecular pathology prior authorization operations for Dana-Farber Cancer Institute administered services.
- Assists staff with complicated clinical or administrative molecular pathology cases with the goal of resolving the prior authorization issue before rendering services.
- 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 a case's complex medical necessity and communicates appropriate medical information to the third-party payer. Completes medical science 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 Manager of Prior Authorizations or Access Management Director.
- Monitors payer policy changes related to drug and molecular pathology prior authorizations. Takes appropriate actions to ensure future services are appropriately identified prior to rendering services.
- Develops and maintains appropriate tools to support drug and molecular pathology prior authorization teams.
- Reviews drug prior authorization workflows, identifies gaps, and implements enhancements to improve processes. Communicates issues to Manager of Prior Authorization.
- Attends regular meetings with the Access Management and/or other Revenue Cycle Departments to discuss revenue cycle issues, implement improvements, and disseminate information appropriately.
- Oversees the daily prior authorization denial workflows including retro authorizations, coordinating peer-to-peer discussions, and writing/filing appeals to the third-party payer.
- Assists with complex prior authorization denials and denial projects. Escalates issues to Manager of Prior Authorization or Access Management Director accordingly.
- Maintains standard operating procedures for the prior authorization team.
- Monitors staffing productivity and delegates daily work accordingly.
- Ensures adequate staffing coverage for required duties.
- Performs other duties as assigned by Manager of Prior Authorization and remains compliant with all departmental and institutional policies.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:- Demonstrates strong ability to train, develop, and oversee clinical and non-clinical staff.
- Demonstrates strong leadership and teamwork skills
- Self-starter with strong analytical, problem solving skills
- Highly organized, able to multi-task and prioritize work quickly and effectively
- Performs well in high-pressure situations
- Superior written and verbal communication skills, knowledge of Microsoft Office products, and technical computing skills
- Strong clinical knowledge with an ability to apply it appropriately and effectively, oncology knowledge a plus.
MINIMUM JOB QUALIFICATIONS:- Bachelor's degree in Nursing required.
- Licensed as a Registered Nurse in the Commonwealth of Massachusetts preferred.
- Minimum 3 years in a Case Management, Utilization Review, and/or related healthcare experience
- 2-3 years of supervisory experience preferred
- Prior patient access experience, revenue cycle experience, and/or payer rules and regulations knowledge required.
SUPERVISORY RESPONSIBILITIES: - Supervise up to fifteen (15) direct reports.
PATIENT CONTACT: 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).
$96,500.00 - $109,100.00
