Infusion Insurance and Prior Authorization Representative

Responsibilities

• Independently manages and strategically evaluates patient referrals for infusion services to determine if insurance and prior authorization criteria are fulfilled to accept or deny the patient for outpatient infusion services.
• Serves as a subject matter expert and uses independent discretion and judgment in interpreting payer policies, medical necessity criteria, and reimbursement requirements.
• Ensures proper and timely insurance authorization, answers infusion financial questions for patients and providers, and documents authorization outcomes to guide optimal and timely infusion service management and administration.
• Manages uninsured and underinsured patient referrals with patient assistance and charity options.
• Serves as a subject matter expert and key operational resource to clinical leadership, revenue cycle leadership, and providers.

Qualifications

Required Qualifications

• High school diploma or GED
• Critical thinking and decisive judgment on authorization matters with financial and operational significance
• Excellent communication, organizational, and customer service skills and ability to work independently
• Knowledge of major medical insurances and proficiency with payer portals and authorization tracking tools
• Knowledge of HCPCS (J-codes) and ICD-10 (diagnosis codes) as they relate to medical and pharmacy benefits for infusion drugs
• Familiarity with medical documentation such as H&Ps, diagnostic imaging, genetic testing, oncology staging
• Ability to read and convert a prescription into an authorization request based on payer requirements
• Ability to interpret medical policies, medical necessity standards, and reimbursement methodologies
• Ability to influence outcomes through judgment, escalation, and problem solving

Preferred Qualification

• 1-2 years progressive experience in pharmacy, medication authorizations, or revenue cycle operations involving independent decision making
• Associate’s or Bachelor’s degree in healthcare administration, business, or related field

Pay

A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $15.50 to $22.45. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Benefits

• Paid time off
• 401K retirement plan
• Medical, dental, and vision coverage
• Tuition reimbursement
• Many more voluntary benefit options