Specialty Financial Clearance Rep Sr

St. Luke's Health System•Boise, ID

4d•Onsite

About The Position

Under limited supervision, the Specialty Financial Clearance Specialist Senior is responsible for securing prior authorizations for complex oncology treatments by demonstrating medical necessity to insurance payers. This role requires a strong understanding of oncology treatments, medical necessity guidelines, medical policies, and payer requirements to prevent treatment delays and ensure compliance. The Specialty Financial Clearance Specialist Senior will work closely with providers, insurance companies, pharmacies and patients to navigate the complex oncology treatment authorization process for chemotherapy, gene therapy, radiation, immunotherapy, oncology procedures, specialty labs, transplants, and other oncology-related services.

Requirements

High School Diploma or equivalent
2 years relevant experience
Possess a strong understanding of oncology treatments, medical necessity guidelines, clinical documentation, medical policies, and payer requirements to prevent treatment delays and ensure compliance.

Responsibilities

Works closely with providers, pharmacy, clinical documentation integrity, coders, insurance companies, and other stakeholders to secure prior authorizations for complex and high dollar treatments such as chemotherapy, stem cell therapies, immunotherapies, targeted therapies, radiation therapies, oncology procedures and off label treatment plans.
Applies and secures financial assistance for specialty labs.
Submits, tracks, and follows up on authorization requests, prioritizing urgent cases as needed.
Collaborates with insurance carrier's appeals teams and clinical teams to resolve denials and appeals efficiently, and coordinate peer-to-peer reviews.
Escalates to external review to the State of Idaho when necessary.
Communicates with insurance companies to clarify requirements, medical necessity indications and guidelines, and authorization requirements.
Coordinates with clinical teams, insurance companies, Patient Financial Navigators to address insurance denials and manage appeals.
Educates patients on insurance benefits, financial responsibility, non-covered services and required payer forms, treatment estimates and alternative coverage options.
Provides updates on authorization status to oncologists, clinical teams, pharmacy, and Patient Financial Navigators.
Maintains accurate records of authorization approvals, denials, and appeals.
Ensures compliance with HIPAA, CMS regulations, and insurance guidelines.
Stays updated on insurance policy changes, medical necessity guideline changes, prior authorization requirements, and oncology treatment protocols and informs colleagues of new information.
May train and mentor others.
Perform other duties as assigned.