The Clinical Authorization Specialist will take the lead in securing medical authorizations from third party payers (commercial and government) for outpatient clinic, inpatient admission, ancillary services and/or chemotherapy and other infused treatments as needed. The Specialist will be instrumental in obtaining written documentation, submitting tracking, reporting and documenting outcomes of each authorization request. The Specialist will be in a position to interface directly with medical/clinical staff and pharmacy to ensure a seamless process to the patients receiving treatment.

Essential Duties:

• Actively obtain written clinical documentation for chemotherapy authorizations in Keckcare for authorization submission from Medical/Nursing Staff
• Submit pre-certification/pre determination documentation to third party payers/payers insurance carrier for authorization with correct CPT and ICD coding
• Research payers medical policy requirements for chemotherapy treatment authorizations and understand process for submitting pre-certification/pre- determination requests
• Utilize Excel Macro tracking log to document authorization requests, follow-up on items and provide outcomes to the Supervisor daily, prior to end of shift.
• Follow-up on outstanding authorization requests and on medical documentation requests in a timely manner.
• Enroll patients in manufacturer patient assistance programs as needed and follow-up regarding enrollment and/or medication reimbursements
• Communicate with a medical/clinical/pharmacy staff and patients on authorization status/outcome.
• Employ compliance checker for Medicare eligible chemotherapy/infusion treatment authorizations and scan/email ABNS to front area reception for signatures as needed.
• Coordinate with Director on denied or disputed claims to obtain documentation to support chemotherapy treatment
• Exhibit sensitivity to the patients at all times concerning privacy and confidentiality while accessing medical records for chemotherapy treatments to process authorizations requests
• Scan all authorizations into Keck care under the respective patient accounts and if applicable, forward authorized orders to pharmacy for dispensing
• Maintain medical policy coverage binder and keep updated with new policies and forms regarding medications FDA indicated usage and authorization requirements.
• Document authorization outcome in all financial systems.
• Performs other duties as assigned.

 
Required Qualifications:

• High school or equivalent Or equivalent evidence in file.

• 2 years Experience in a hospital, medical office/doctor’s office or working for a health insurer.

• Excellent time management, organizational skills, research/analytical skills, negotiation, communication (written and verbal), and interpersonal skills
• Able to function independently and as a member of a team.
• Demonstrate excellent customer service behavior.

Preferred Qualifications:

• Experience in area of service.
• Medical Prior Authorizations or Claims experience in a managed care setting.
• Oncology experience.

• Knowledge of medical terminology.
•  Knowledge of the health insurance industry and claims processing.

Required Licenses/Certifications:

• Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)