Clinical Authorization Specialist
Company: Dana-Farber Cancer Institute
Posted on: November 15, 2022
Clinical Authorization Specialist
Job DetailsJob ID:
10 Brookline Place West, Brookline, MA 02445
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:
- 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
- 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
- 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
- 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
- Serve as a clinical resource to the Revenue Integrity and
Billing Compliance team.
- Bachelor's degree required.
- 1 year clinical and/or related experience required. Case
Management, Utilization Review and/or Prior Authorization
experience is preferred.
- Licensed as a Registered Nurse in the Commonwealth of
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:
- Ability to mentor and educate team members, including by
- Ability to function independently and prioritize work within
- 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
- 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
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
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