Specialist-Authorization Denial

Baptist • Memphis, TN

9h

About The Position

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. Performs other duties as assigned.

Requirements

• 3 – 5 years of business experience in a healthcare environment with 2 of those years being in a clinical setting.
• 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 judgement.
• Excellent customer service and communication skills.
• Ability to speak, articulate, and be understood clearly.
• Ability to read and understand medical policies, compendiums, LCDs, and FDA guidelines.
• Must be able to multi-task and be flexible.
• Advance computer literacy skills and problem solving skills.
• Ability to deal with confrontational issues and high stress situations with patients, family, and physicians.

Nice To Haves

• 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.
• Associates degree or 2 years of college level courses.
• Must demonstrate the ability to appropriately use standard criteria established by payers.
• Knowledge of oncology pre-certification requirements and guidelines.
• Pharmacy Tech, CHAA, RHIT, LPN, RN

Responsibilities

• Obtain and review treatment/therapy plan orders for medical necessity and appropriateness according 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
• Responsible for tracking, obtaining, and extending authorizations from various carriers in a timely manner
• Responsible for completing the Insurance Verification process
• Works closely with physicians and clinic staff obtain authorizations to promote positive patient outcomes, timely treatment and positive reimbursement
• Understands and complies with regulatory requirements by specific insurance companies and facilitates compliance by maintaining awareness of guidelines and ensuring compliance through communication and documentation to appropriate staff.
• Reviews, assesses and evaluates all authorization denial communications received in order to optimize reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees