POSITION SUMMARY:
Reporting to the Radiology Authorization Supervisor, the Radiology Authorization Specialist is responsible for independently managing all work related to medical necessity-based authorizations for all diagnostic imaging services ordered by Dana-Farber Cancer Institute (DFCI) providers.
Working in a fast-paced, high-volume, dynamic environment, the Radiology Authorization Specialist will demonstrate strong understanding of payer coverage policies, applying appropriate payer guidelines to all aspects of radiology prior authorization work. The Specialist will leverage their strong understanding of medical terminology and physiology to retrieve the appropriate clinical documents (e.g., progress notes, lab values, scan results) from within the electronic medical record (EMR). The Radiology Authorization Specialist will create thorough, concise prior authorization requests to all payers.
MINIMUM JOB QUALIFICATIONS: - High school diploma or equivalent required; Associate's or bachelor's degree preferred.
- 1 year of relevant work experience in a hospital or ambulatory setting, including hospital/physician office work, prior authorization, financial counseling and billing experience required. Other relevant experiences include but are not limited to healthcare/business administration, health insurance, medical policy review and/or pharmacy.
PRIMARY DUTIES AND RESPONSIBILITIES: - Reviews and monitors all radiology authorization work queues and independently identifies and prioritizes imaging procedures with the greatest financial reimbursement risk.
- Reprioritizes work to respond to clinically urgent diagnostic imaging procedures and produces high quality work under pressure.
- Verifies insurance eligibility and benefits, utilizing automated eligibility systems, payer portals, or telephone communication.
- Prepares and completes payer-specific prior authorization requests, interprets medical policy criteria, and applies appropriate guidelines to prior authorization requests.
- Reviews and comprehends patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care. Identifies appropriate medical documentation to satisfy payer medical policy criteria.
- Responds to health plan-reviewed prior authorization requests that do not meet initial policy criteria. Works with the health plan to resolve issues and/or coordinates appropriate provider-to-health plan interventions (e.g., peer-to-peer discussions, letters of medical necessity, provider-initiated appeals, etc.).
- Follows-up with patients in the case of denied coverage of a radiology exam. Provides superior customer service to all patients, works through patient-raised issues, and recommends appropriate solutions.
- Completes appropriate post-claim denial follow-up to overturn radiology-related prior authorization claim denials.
- Performs other work duties and projects as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED: - Strong understanding and ability to work in various computing/information systems and Microsoft Office product suite.
- Demonstrated knowledge of third-party payer rules and regulations.
- Strong understanding of medical terminology and physiology.
- Strong analytical and problem-solving skills.
- Ability to function independently and prioritize work within established policies.
- Ability to work with sensitive patient information and maintain confidentiality.
- Ability to work closely and effectively with colleagues across the organization including clinical staff.
- Ability to use good judgment, tact, and sensitivity.
- Ability to function in a fast paced, highly demanding environment.
SUPERVISORY RESPONSIBILITIES:NonePATIENT CONTACT: IndirectThe 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).
$135,200.00 - $161,500.00
