Specialist-Authorization Denial

Summary

Authorization Denial Specialist ensures that chemotherapy (specialty group) and other infusions/radiation therapy/radiology/ surgical services meet medical necessity and appropriateness per insurance medical policies/ FDA/NCCN guidelines. Initiates and coordinates pre-certifications/prior authorizations per payer guidelines prior to services being rendered and completes the Insurance verification process.

Reviews clinical information and supporting documentation for outpatient or Part B services authorization denials to determine and perform retro authorizations, reconsiderations or appeal actions to defend the revenue. Performs other duties as assigned.

Responsibilities

•    Obtain and review treatment/therapy plan orders for medical necessity and appropriateness according to insurance medical policy/FDA/NCCN guidelines and requirements.
•    Research insurance company medical policies, medical literature, and compendiums to determine eligibility for services. Utilize multiple healthcare websites
•    Responsible for tracking, obtaining, and extending authorizations from various carriers in a timely manner
•    Responsible for completing the Insurance Verification process
•    Works closely with physicians and clinic staff obtain authorizations to promote positive patient outcomes, timely treatment and positive reimbursement
•    Understands and complies with regulatory requirements by specific insurance companies and facilitates compliance by maintaining awareness of guidelines and ensuring compliance through communication and documentation to appropriate staff.
•    Reviews, assesses and evaluates all authorization denial communications received in order to optimize reimbursement
Requirements, Preferences and Experience

Minimum Required
3 – 5 years of business experience in a healthcare environment with 2 of those years being in a clinical setting.
Preferred/Desired
5 years of business experience in a healthcare environment with at least 3 years payer specific experience.
3 years clinical experience in a clinical care setting
Pre-certification experience desired.

Education
Minimum Required
Skill in communicating clearly and effectively using standard English in written, oral, and verbal format to achieve high productivity and efficiency. Skill to write legibly and record information accurately as necessary to perform job duties. Strong organizational skills. Ability to type and/or key correctly
Preferred/Desired
Associates degree or 2 years of college level courses.

Training
Minimum Required
Requires critical thinking and judgement.

Preferred/Desired
Must demonstrate the ability to appropriately use standard criteria established by payers.
Special Skills
Excellent customer service and communication skills. Ability to speak, articulate, and be understood clearly.

Minimum Required
Ability to read and understand medical policies, compendiums, LCDs, and FDA guidelines. Must be able to multi-task and be flexible. Advance computer literacy skills and problem-solving skills. Ability to deal with confrontational issues and high stress situations with patients, family, and physicians.
Preferred/Desired
Knowledge of oncology pre-certification requirements and guidelines.
Licensure

Preferred/Desired
Pharmacy Tech, CHAA, RHIT, LPN, RN
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