Clinical Authorization Specialist - USC Cancer Center LA - Full Timed 8 Hour Days (Non-Exempt) (Non-Union)

University of Southern California•Los Angeles, CA

About The Position

The Clinical Authorization Specialist leads efforts to secure medical authorizations from commercial and government third-party payers for outpatient clinic services, inpatient admissions, ancillary services, chemotherapy and other infused treatments, and other procedures as needed in the assigned service line. The Specialist obtains and submits clinical documentation, tracks authorization requests, records outcomes, and coordinates with medical, clinical, and pharmacy staff to support a seamless treatment process for patients. This position reports to the Administrative Clinic Manager and assists with operations at the Koreatown/Buena Park Medical Oncology/Multi-Disciplinary Clinic. The role includes researching payer medical policies and authorization requirements; submitting pre-certification and pre-determination requests with appropriate CPT and ICD coding; maintaining tracking records and financial-system documentation; following up on pending requests and documentation; and communicating authorization status to staff and patients. The Specialist also supports patient enrollment in manufacturer assistance programs, processes Medicare compliance checks, maintains current medication coverage policies and forms, and handles medical records with sensitivity to patient privacy and confidentiality.

Requirements

High school diploma or equivalent, or equivalent evidence on file.
At least 2 years of experience in a hospital, medical or doctor's office, or for a health insurer.
Excellent time management, organizational, research and analytical, negotiation, written and verbal communication, and interpersonal skills.
Ability to function independently and as a member of a team.
Demonstrated excellent customer service behavior.
Fire Life Safety Training (LA City); if the card is not held upon hire, it must be obtained within 30 days of hire and maintained through renewal before expiration. Required within LA City only.

Nice To Haves

Experience in the area of service.
Medical prior authorization or claims experience in a managed care setting.
Ophthalmic experience.
Knowledge of medical terminology.
Knowledge of the health insurance industry and claims processing.

Responsibilities

Obtain written clinical documentation from medical and nursing staff for ambulatory consultations and examinations, OT/PT, procedures, treatments, and other authorization requests.
Submit pre-certification and pre-determination documentation to third-party payers using correct CPT and ICD coding.
Research payer medical policy requirements and understand submission processes for authorization requests.
Use an Excel tracking log to document requests, follow up on items, and provide outcomes to the Supervisor daily before the end of the shift.
Follow up promptly on outstanding authorization requests and requests for medical documentation.
Enroll patients in manufacturer patient assistance programs as needed and follow up on enrollment and medication reimbursements.
Communicate authorization status and outcomes to medical, clinical, and pharmacy staff and patients.
Use the compliance checker for Medicare-eligible services and scan or email ABNS to front-area reception for signatures as needed.
Coordinate with the Director on denied or disputed claims and obtain supporting documentation.
Protect patient privacy and confidentiality when accessing medical records to process authorization requests.
Scan authorizations into Keckcare under the relevant patient accounts and forward authorized orders to the pharmacy for dispensing when applicable.
Maintain and update the medical policy coverage binder, including policies and forms related to FDA-indicated medication use and authorization requirements.
Document authorization outcomes in all financial systems.
Perform other duties as assigned.