Clinical Authorization Specialist

• 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 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:

• 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:

• 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.
• Performs other duties as assigned.

• Minimum Education:

• Bachelor’s degree required. BSN preferred.
• Minimum Experience:

• 1 year of clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred.
• Certification/Licensure/Registration:

• Licensed as a Registered Nurse in the Commonwealth of Massachusetts preferred.

• Knowledge of third-party payer rules and regulations highly desirable.
• Good judgment, tact, sensitivity, and the ability to function in a fast paced, highly demanding environment.
• Analytical and problem-solving skills.
• Understanding and ability to work in various computing/information systems and Microsoft Office product suite.
• 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.
• Ability to work with sensitive patient information and maintain confidentiality.
• Ability to work closely and effectively with colleagues across the organization including medical staff.

Dana-Farber Cancer Institute