The Senior Infusion Insurance and Prior Authorization Coordinator provides expert-level support to the infusion prior authorization team related to commercial vs government and oncology vs non-oncology therapy workflows. The position participates in implementing prior authorization workflows for new acquisition infusion centers and validating maintenance of prior authorization workflows at existing infusion centers.  This position independently manages and strategically evaluates patient referrals for infusion services to determine if insurance and prior authorization criteria are fulfilled to either accept or deny the patient for outpatient infusion services. This position serves as a subject matter expert and uses independent discretion and judgement in interpreting payer policies, medical necessity criteria, and reimbursement requirements. This position ensures proper and timely insurance authorization, answers infusion financial questions for patients and providers, and documents authorization outcomes to guide optimal and timely infusion service management and administration. This position manages uninsured and underinsured patient referrals with patient assistance and charity options. This position serves as a subject matter expert and key operational resource to clinical leadership, revenue cycle leadership, providers, and prior authorization coordinators. 

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. High school diploma or GED
2. At least 2 years of oncology infusion prior authorization experience
3. Knowledge of medication generic and biosimilar options as they relate to net financial outcomes
4. Critical thinking and decisive judgment on authorization matters with financial and operational significance
5. Excellent communication, organizational, and customer service skills and ability to work independently
6. Knowledge of major medical insurances and proficiency with payer portals and authorization tracking tools
7. Knowledge of HCPCS (J-codes) and ICD-10 (diagnosis codes) as they relate to medical and pharmacy benefits for infusion drugs
8. Familiarity with medical documentation such as H&Ps, diagnostic imaging, genetic testing, oncology staging
9. Ability to read and convert a prescription into an authorization request based on payer requirements
10. Ability to make drug option selections based on medical policies, medical necessity standards, and reimbursement methodologies
11. Ability to influence outcomes through judgement, escalation, and problem solving

Preferred qualification:

1. 4 years of oncology infusion prior authorization experience
2. 1-2 years progressive experience in pharmacy, medication authorizations, or revenue cycle operations involving independent decision making
3. Experience in Meditech, Mosaiq, Epic, Cerner and/or comparable oncology billing software
4. Associate’s or Bachelor’s degree in healthcare administration, business, or related field
5. Certification or studies in coding, medical terminology or revenue cycle processes

Saint Francis Hospital offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $XXX,XXX.XX to $XXX,XXX.XX on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

The company is dedicated to empowering its staff with a comprehensive, competitive benefits package, allowing them the freedom to customize their benefits to fit their unique needs. Our abundant resources, programs, and voluntary options serve as a foundation for individual growth and well-being. Learn more here: https://www.primehealthcare.com/benefitsthatmattermost/

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf