Infusion Insurance and Prior Authorization Coordinator

Olympia Fields Hospital•Rich Township, IL

About The Position

The Infusion Insurance and Prior Authorization Coordinator independently manages and strategically evaluates patient referrals for infusion services to determine if insurance and prior authorization criteria are fulfilled to either accept or deny the patient for outpatient infusion services. This position serves as a subject matter expert and uses independent discretion and judgement in interpreting payer policies, medical necessity criteria, and reimbursement requirements. This position 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. This position manages uninsured and underinsured patient referrals with patient assistance and charity options. This position serves as a subject matter expert and key operational resource to clinical leadership, revenue cycle leadership, and providers.

Requirements

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 judgement, escalation, and problem solving

Nice To Haves

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

Responsibilities

Independently manages and strategically evaluates patient referrals for infusion services to determine if insurance and prior authorization criteria are fulfilled to either accept or deny the patient for outpatient infusion services.
Serves as a subject matter expert and uses independent discretion and judgement 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.