Drug Authorization Specialist

• Reviews and monitors the drug authorization work queue and independently identifies and prioritizes patient treatment/therapy plans that require prior authorization.
• Reprioritizes work to respond to clinically urgent treatment and therapy plans and produces high quality work under pressure.
• Verifies insurance eligibility and benefits, utilizing automated eligibility systems, payer portals, and/or telephone communication.
• Assists patients with resolving insurance related issues prior to initiating treatment.
• Prepares and completes payer-specific prior authorization request forms, interprets medical policy criteria, and applies appropriate guidelines to prior authorization requests.
• Reviews and comprehends patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care. Identifies appropriate medical documentation that satisfies payer medical policy criteria.
• Responds to health plan-reviewed prior authorization requests that do not meet initial policy criteria. Works with the health plan to resolve issues and/or coordinates appropriate provider-to-health plan interventions (e.g., peer-to-peer discussions, letters of medical necessity, provider-initiated appeals, etc.).
• Manages prior authorization reports to ensure appropriate drug dispenses are appropriately authorized and followed-up on.
• Monitors and reports changes in payer prior authorization requirements to update and maintain prior authorization tools and spreadsheets.
• Completes appropriate post-claim denial follow-up to overturn drug-related prior authorization claim denials.
• Maintains digital archiving of prior authorizations to support post-claim denial workflows.
• Assists with the training of new staff and performs other work duties and projects as assigned.
• Performs other duties as assigned.

• Minimum Education:

• High school diploma or GED required; bachelor’s degree with a science related background preferred.
• Minimum Experience:

• 0 years of experience required; 1 year of relevant work experience in a hospital or ambulatory setting, including hospital/physician office work, prior authorization, financial counseling, and billing experience preferred.

• Knowledge of third-party payer rules and regulations.
• Good analytical and problem-solving skills.
• Excellent customer service and communication skills, both written and verbal.
• Ability to function independently and prioritize work within established policies.
• Ability to work closely and effectively with colleagues across the organization including clinical staff.
• Ability to work with sensitive patient information and maintain confidentiality.
• Ability to prioritize and meet pre-determined deadlines.
• Ability to use good judgment, tact, and sensitivity.
• Ability to function in a fast paced, highly demanding environment.

Dana-Farber Cancer Institute