Specialty Financial Clearance Rep

St. Luke's Health System•Boise, ID

11d

About The Position

At St. Luke’s, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke’s is truly a great place to work. What You Can Expect: Under general supervision, the Specialty Financial Clearance Specialist will be responsible for securing prior authorizations for less complex oncology treatments. This includes but is not limited to chemotherapy, radiation therapy, immunotherapy, oncology procedures, specialty labs and supportive medications. This role ensures that patients receive timely treatment by coordinating with insurance providers, healthcare teams, and Patient Financial Advocates to navigate the complexities of insurance coverage and minimize delays in care. The objective is to reduce financial barriers and delays in care while adhering to payer guidelines. Works with providers, pharmacists, pharmacy staff, coders, and insurance companies, to navigate the treatment authorization process and secure prior authorizations for oncology treatments, surgeries, specialty drugs, specialty labs, supportive care and other oncology-related services. Handles routine and lower-complexity oncology treatment plan and service authorizations referring the more complex cases to the Senior Specialist. Possess a working knowledge of oncology treatments, medical necessity guidelines, clinical documentation, medical policies, and payer requirements to prevent treatment delays and ensure compliance. Submits, tracks, and follows up on authorization requests, prioritizing urgent cases as needed. Collaborates with insurance carrier appeal teams and clinical teams to resolve denials and appeals efficiently, and coordinates peer-to-peer reviews. Communicates with insurance carriers to clarify policies, coverage limitations, and pre-certification requirements. Coordinates with clinical teams, insurance companies and Patient Financial Navigators to address insurance denials and manage appeals. Educates patients on insurance benefits, financial responsibility, and alternative coverage options. Provides updates on authorization status to clinical teams, oncologists, 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, prior authorization trends, and oncology treatment protocols. Performs other duties as assigned

Requirements

High School Diploma or equivalent
1-year relevant experience
Possess a working knowledge of oncology treatments, medical necessity guidelines, clinical documentation, medical policies, and payer requirements to prevent treatment delays and ensure compliance

Responsibilities

Securing prior authorizations for less complex oncology treatments
Coordinating with insurance providers, healthcare teams, and Patient Financial Advocates to navigate the complexities of insurance coverage and minimize delays in care
Working with providers, pharmacists, pharmacy staff, coders, and insurance companies, to navigate the treatment authorization process and secure prior authorizations for oncology treatments, surgeries, specialty drugs, specialty labs, supportive care and other oncology-related services
Handling routine and lower-complexity oncology treatment plan and service authorizations referring the more complex cases to the Senior Specialist
Submitting, tracking, and following up on authorization requests, prioritizing urgent cases as needed
Collaborating with insurance carrier appeal teams and clinical teams to resolve denials and appeals efficiently, and coordinates peer-to-peer reviews
Communicating with insurance carriers to clarify policies, coverage limitations, and pre-certification requirements
Coordinating with clinical teams, insurance companies and Patient Financial Navigators to address insurance denials and manage appeals
Educating patients on insurance benefits, financial responsibility, and alternative coverage options
Providing updates on authorization status to clinical teams, oncologists, and Patient Financial Navigators
Maintaining accurate records of authorization approvals, denials, and appeals
Ensuring compliance with HIPAA, CMS regulations, and insurance guidelines
Staying updated on insurance policy changes, prior authorization trends, and oncology treatment protocols
Performing other duties as assigned