Specialist-Authorization Denial

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.