Clinical Authorization Specialist

Company: Dana-Farber Cancer Institute
Location: Brookline
Posted on: November 15, 2022

Job Description:

Clinical Authorization Specialist

Job DetailsJob ID:
31923

Location:
10 Brookline Place West, Brookline, MA 02445

Category:
Finance/Accounting

Employment Type:
Full time

Work Location:
Full Remote: 4-5 days remote/wk
OverviewReporting to the Drug Authorization Supervisor, the Clinical Authorization Specialist is responsible for independently managing all work related to molecular pathology, high-cost drug, and off-label drug authorizations. The Clinical Authorization Specialist is also responsible for independently managing denials related to front-end prior authorization, biosimilar drugs, pharmacy-benefit exclusion drugs, and claims.Working in a fast-paced, high volume, dynamic environment, the Clinical Authorization Specialist will bring clinical expertise to the prior authorization and appeals processes and serve as a liaison and patient advocate between Dana Farber Cancer Institute and various health plans.Located in Boston and the surrounding communities, Dana-Farber Cancer Institute brings together world renowned clinicians, innovative researchers and dedicated professionals, allies in the common mission of conquering cancer, HIV/AIDS and related diseases. Combining extremely talented people with the best technologies in a genuinely positive environment, we provide compassionate and comprehensive care to patients of all ages; we conduct research that advances treatment; we educate tomorrow's physician/researchers; we reach out to underserved members of our community; and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.ResponsibilitiesPRIMARY DUTIES AND RESPONSIBILITIES:

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• Manages approval process for clinically complex cases:
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  • 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:
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    • 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:
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      • 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.
        QualificationsMinimum Education:
        
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        • Bachelor's degree required.
          Minimum Experience:
          
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          • 1 year clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred.
            License/Certification/Registration:
            
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            • Licensed as a Registered Nurse in the Commonwealth of Massachusetts preferred.
              KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:
              
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              • 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.
              • Good judgment, tact, sensitivity and the ability to function in a fast paced, highly demanding environment.
              • Ability to work with sensitive patient information and maintain confidentiality.
              • Demonstrated knowledge of third-party payer rules and regulations highly desirable.
              • Ability to work closely and effectively with colleagues across the organization including medical staff.
              • Shows strong analytical and problem-solving skills.
              • Strong understanding and ability to work in various computing/information systems and Microsoft Office product suite.
                Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are equally committed to diversifying our faculty and staff. Cancer knows no boundaries and when it comes to hiring the most dedicated and diverse professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other groups as protected by law.

Keywords: Dana-Farber Cancer Institute, Brookline , Clinical Authorization Specialist, Healthcare , Brookline, Massachusetts