Specialist-Authorization Denial

About the role

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.

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.
• Track, obtain, and extend authorizations from various carriers in a timely manner.
• Complete the insurance verification process.
• Work closely with physicians and clinic staff to obtain authorizations to promote positive patient outcomes, timely treatment, and positive reimbursement.
• Understand and comply with regulatory requirements by specific insurance companies and facilitate compliance by maintaining awareness of guidelines and ensuring compliance through communication and documentation to appropriate staff.
• Review, assess, and evaluate all authorization denial communications received in order to optimize reimbursement.

Minimum Required Requirements, Preferences and Experience

• 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

• Associates degree or 2 years of college-level courses.

Minimum Required Skills

• 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.
• Requires critical thinking and judgment.
• Ability to read and understand medical policies, compendiums, LCDs, and FDA guidelines.
• Must be able to multi-task and be flexible.
• Advanced computer literacy skills and problem-solving skills.
• Ability to deal with confrontational issues and high-stress situations with patients, family, and physicians.

Preferred/Desired Skills

• Excellent customer service and communication skills.
• Ability to speak, articulate, and be understood clearly.
• Knowledge of oncology pre-certification requirements and guidelines.

Licensure

• Pharmacy Tech, CHAA, RHIT, LPN, RN.