Purpose of Position and Scope of Responsibility

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.

Principal Accountabilities/Responsibilities

• Obtain and review treatment/therapy plan orders for medical necessity and appropriateness according to 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.
• Track, obtain, and extend authorizations from various carriers in a timely manner.
• Complete 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.
• Collaborates with denial team to education denial specialists and clinical staff on trending in authorization and medical necessity denials.
• Complete other duties as assigned.

Minimum Qualifications

3 – 5 years of business experience in a healthcare environment with 2 of those years being in a clinical setting.

Desired Qualifications

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.