Sr Clinical Authorization Spec

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…