Specialist-Authorization Denial

Overview

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.

Job 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.
• Responsible for tracking, obtaining, and extending authorizations from various carriers in a timely manner.
• Responsible for completing the Insurance Verification process.
• Works closely with physicians and clinic staff to 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.

Requirements, Preferences and Experience

Education

Preferred: Associates degree or 2 years of college level courses.

Minimum: Skill in communicating clearly and effectively using standard English in written, oral, and verbal format to achieve high productivity and efficiency. Skill to write legibly and record information accurately as necessary to perform job duties.

Experience

Preferred: 5 years of business experience in a healthcare environment with at least 3 years payer specific experience.

Minimum: 3 years clinical experience in a clinical care setting. Pre-certification experiences desired.

Special Skills

Preferred: Education Minimum Required 3 – 5 years of business experience in a healthcare environment with 2 of those years being in a clinical setting. Preferred/Desired 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. Education Minimum Required Skill in communicating clearly and effectively using standard English in written, oral, and verbal format to achieve high productivity and efficiency. Skill to write legibly and record information accurately as necessary to perform job duties. Strong organizational skills. Ability to type and/or key correctly. Preferred/Desired Associates degree or 2 years of college level courses. Training Minimum Required Requires critical thinking and judgement. Preferred/Desired Must demonstrate the ability to appropriately use standard criteria established by payers. Special Skills Excellent customer service and communication skills. Ability to speak, articulate, and be understood clearly. Minimum Required Ability to read and understand medical policies, compendiums, LCDs, and FDA guidelines. Must be able to multitask and be flexible. Advance computer literacy skills and problem-solving skills. Ability to deal with confrontational issues and high stress situations with patients, family, and physicians.

Minimum: Knowledge of oncology pre-certification requirements and guidelines.

Licensure, Registration, Certification

Preferred: Pharmacy Tech, CHAA, RHIT, LPN, RN

About Baptist Memorial Health Care

At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry—healing, preaching, and teaching. And we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums, and the results of a Benefits Benchmarking Survey.

At Baptist, We Offer:

• Competitive salaries
• Paid vacation/time off
• Continuing education opportunities
• Generous retirement plan
• Health insurance, including dental and vision
• Sick leave
• Service awards
• Free parking
• Short-term disability
• Life insurance
• Health care and dependent care spending accounts
• Education assistance/continuing education
• Employee referral program

Category: Finance and Accounting
Type: Non-Clinical
Work Type: Full Time
Work Schedule: Days
Location: US: Memphis, TN
Located in the Memphis, TN area