Reporting to the Prior Authorization Supervisor, the Senior Clinical Authorization Specialist is primarily responsible for assisting the supervisor with daily team operations, including but not limited to providing feedback on authorization processes, providing support to staff as necessary and assisting the Drug Authorization Supervisor in educating Authorization staff of any changes pertaining to their roles and responsibilities.

This Senior Clinical Authorization Specialist is also responsible for submitting prior authorizations, obtaining insurance authorizations for high-cost drug, off-label drug, and other clinical services, such as molecular pathology, confirming insurance eligibility, appealing both pre and post claim denials, and completing assigned work in a timely and accurate fashion.

PRIMARY DUTIES AND RESPONSIBILITIES:

With minimal 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.
  • Assists in the mentoring of staff.
  • Assists in developing and maintaining training materials and other resources.
  • Provides escalation support and manages more complex situations and cases.
  • Provides feedback for quality or process improvement initiatives and projects, as required.
  • Assists Drug Authorization Supervisor in monitoring the daily drug prior authorization processes 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 meeting insurance requirements and pursuing insurance approval for complicated clinical or administrative drug cases with the goal of resolving the prior authorization issue before rendering the service.
  • Assists in resolving patient and clinic concerns surrounding prior authorization.
  • Trains new and/or existing employees.
  • Provides feedback to the supervisor on staff performance.
  • Assists clinical staff with complicated off-label chemotherapy with the goal of resolving coverage issues; escalates complicated administrative cases to Drug Authorization Supervisor or Manager of Prior Authorization.
  • 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 necessity and communicates appropriate medical information to the insurer.
    • 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 Drug Authorization Supervisor or Manager of Prior Authorizations.
• Assists in the oversight of the daily prior authorization denial workflows including retro authorizations, coordinating peer-to-peer discussions, and writing/filing appeals to the third-party payer.
• Performs other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

• Strong knowledge of third-party payer rules and regulations highly desirable.
• Strong judgment, tact, sensitivity, and the ability to function in a fast paced, highly demanding environment.
• Strong analytical and problem-solving skills.
• Strong 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:

4 years of clinical and/or related experience required. 2 years of previous experience in a Clinical Authorization Specialist II role required.

Certification/Licensure/Registration:

Licensed as a Registered Nurse in the Commonwealth of Massachusetts 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).

$110,200.00 - $123,200.00