Advance Authorization Specialist

Overview

Job Summary

Responsible for all aspects involved in obtaining highly complex authorizations for a multitude of In-patient and Out-patient Services. The Advance Authorization Specialist must be knowledgeable and have a thorough understanding of Commercial and Government payors with regards to Coordination of Benefits, Authorization guidelines, Pharmacy and Medical Benefit variances, as well as Medical Necessity Policies. The Advance Authorization Specialist is responsible for reading and interpreting various complex medical records to obtain authorizations for requested services and treatment plans. Communication with clinic staff, providers, Pharmacists, and insurance companies is essential to ensure completed peer reviews, relay updated medical and specialty drug policies, and appeals. They work closely with the Hospital and Provider Denial Management Teams to review monthly denials and assess opportunities for retro-active authorizations and determine root cause analysis.

Essential Functions

• Assess time sensitive Referral Work Queues to obtain highly complex authorizations including IP/OP Chemotherapy, Radiology, specifically related to Oncology treatment plans, IP/OP Surgeries, Molecular and Genetic Laboratory Testing, specialty related PT/OT and Speech Therapy, Psychiatry, Neuro/Psych Evaluations, and Rehab evaluations.
• Manage high volume Stat request mailbox for all oncology facilities for potential life altering, high-cost treatment and procedures within a short time frame. Expected treatment within 1-3 days.
• Interpret medical records to determine initial and disease progression to prove medical necessity for ordered services and complete on-line clinical requests for advance authorization.
• Manage Atrium Health preferred drug list (chemotherapy/immunotherapy/supportive drugs) with payors and correlate changes with oncology Pharmacy.
• Manage Atrium Health drug formulary changes with authorization updates with payors.
• Review laboratory panels for Bone Marrow Biopsies to authorize Molecular Lab Studies, diagnosis specific.
• Review and address monthly denials for Chemotherapy Drugs, Molecular Labs and surgeries with payors and Atrium Health Denial Management Teams (HBO/PBO).

Education, Experience and Certifications

Bachelor's Degree or 3 years of authorizations experience in oncology required. General knowledge and background in CPT and HCPCS Coding. Must be proficient with medical terminology and be familiar with clinical considerations as these relate to oncology services. Excellent written and oral communication skills required. Microsoft Excel, Word, Epic experience preferred. Databases, hospital registration, billing and clinical systems preferred.

Addendum

Additional Essential Functions

• Manage daily reports for procedures and diagnostic test needing retro authorizations
• Obtaining authorizations for complex diagnostic tests and procedures for the following specialties: Heart Failure, Structural Heart, Cath/Angiograms, Cardiac Surgery, Vascular Surgery, Thoracic Surgery, Electrophysiology, Vein, and Advanced Imaging
• Training and onboarding new teammates on all the cardiovascular specialties
• Reviewing monthly insurance payor updates related to cardiology and educating teammates on relevant changes
• Providing pricing estimates for diagnostics and procedures
• Review and address denials for diagnostic and surgeries with payors and Atrium Health Denial Management

Additional Training and Certifications

• Bachelor's Degree or 3 years of authorizations experience in cardiology required.
• Training in all sanger specialties preferred: adult cardiology, electrophysiology, structural heart, vascular, heart failure, vein, thoracic surgery, and cardiac surgery