Job Description
The Drug Authorization Specialist, with direct supervision of the Prior Authorization Supervisor, is responsible for managing all work related to drug authorizations for all injectable drug treatment plans ordered by Dana Farber Cancer Institute providers using knowledge of payer coverage policies and applies appropriate payer guidelines to all aspects of drug prior authorization work.
The Drug Authorization Specialist creates accurate, thorough, and concise prior authorization requests to all payers leveraging understanding of medical terminology and physiology to retrieve the appropriate clinical documents (e.g., progress notes, lab values, scan results) from within the electronic medical record (EMR).
Located in Boston and the surrounding communities, Dana-Farber Cancer Institute is a leader in life changing breakthroughs in cancer research and patient care. We are united in our mission of conquering cancer, HIV/AIDS and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.
With Direct Supervision, The Drug Authorization Specialist - Reviews and monitors the drug authorization work queue and independently identifies and prioritizes patient treatment/therapy plans that require prior authorization.
- Reprioritizes work to respond to clinically urgent treatment and therapy plans and produces high quality work under pressure.
- Verifies insurance eligibility and benefits, utilizing automated eligibility systems, payer portals, and/or telephone communication.
- Assists patients with resolving insurance related issues prior to initiating treatment.
- Prepares and completes payer-specific prior authorization request forms, interprets medical policy criteria, and applies appropriate guidelines to prior authorization requests.
- Reviews and comprehends patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care. Identifies appropriate medical documentation that satisfies payer medical policy criteria.
- Responds to health plan-reviewed prior authorization requests that do not meet initial policy criteria. Works with the health plan to resolve issues and/or coordinates appropriate provider-to-health plan interventions (e.g., peer-to-peer discussions, letters of medical necessity, provider-initiated appeals, etc.).
- Manages prior authorization reports to ensure appropriate drug dispenses are appropriately authorized and followed-up on.
- Monitors and reports changes in payer prior authorization requirements to update and maintain prior authorization tools and spreadsheets.
- Completes appropriate post-claim denial follow-up to overturn drug-related prior authorization claim denials.
- Maintains digital archiving of prior authorizations to support post-claim denial workflows.
- Assists with the training of new staff and performs other work duties and projects as assigned.
- Performs other duties as assigned.
- Minimum Education:
- High school diploma or GED required; bachelor’s degree with a science related background preferred.
- Minimum Experience:
- 0 years of experience required; 1 year of relevant work experience in a hospital or ambulatory setting, including hospital/physician office work, prior authorization, financial counseling, and billing experience preferred.
Knowledge, Skills, And Abilities Required - Knowledge of third-party payer rules and regulations.
- Good analytical and problem-solving skills.
- Excellent customer service and communication skills, both written and verbal.
- Ability to function independently and prioritize work within established policies.
- Ability to work closely and effectively with colleagues across the organization including clinical staff.
- Ability to work with sensitive patient information and maintain confidentiality.
- Ability to prioritize and meet pre-determined deadlines.
- Ability to use good judgment, tact, and sensitivity.
- Ability to function in a fast paced, highly demanding environment.
At Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are equally committed to diversifying our faculty and staff. Cancer knows no boundaries and when it comes to hiring the most dedicated and diverse professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.
Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law.
EEOC Poster
Job Tags
Work experience placement, Work at office,