Job Description
Position Summary:
Coordinates and facilitates administrative processes and services at a center or program necessary to deliver and support the care for patients with chronic disease. Serves as the center or program’s point person for managing the prior authorization process for treatments involving specialized medicines and medical procedures across providers in multiple specialties. Coordinates communications and services with insurance companies, medical device and supply companies, and specialty pharmacy companies in support of providers’ care. Provides training and guidance to center/program staff on related administrative processes and procedures.
Key Responsibilities:
Authorizations
Process Improvement
Minimum Qualifications
Education:
Coordinates and facilitates administrative processes and services at a center or program necessary to deliver and support the care for patients with chronic disease. Serves as the center or program’s point person for managing the prior authorization process for treatments involving specialized medicines and medical procedures across providers in multiple specialties. Coordinates communications and services with insurance companies, medical device and supply companies, and specialty pharmacy companies in support of providers’ care. Provides training and guidance to center/program staff on related administrative processes and procedures.
Key Responsibilities:
Authorizations
- Manages the authorization process for a significant variety of medicines, specialized treatments, medical procedures, etc. for patients across multiple providers and specialties. Prepares letters of medical necessity based on physician’s notes.
- Under supervision, coordinates with insurance companies, specialty pharmacies and patient’s families for the delivery of the specialized treatments during clinic visits.
- Coordinates appeals with clinicians and patient families by preparing letters of appeal or connecting the clinician directly with the insurance company.
- Serves as point of contact and subject matter expert on the process for obtaining and responding to additional requests for prior authorizations across relevant insurance companies for supported clinical area. Coordinates as necessary with pharmaceutical companies to improve processes for obtaining authorizations for the most complex drugs.
- Answers, screens and routes a high volume of phone and email inquiries from patients and families and external companies in coordination of services. Records and forwards messages and triages calls to nurses, physicians and numerous other providers for urgent information or services.
- Responds to patient’s concerns and needs within scope of knowledge and authority and in accordance with our best practices and procedures. Responds to situations requiring escalated service response, ensuring the appropriate providers and parties across multiple specialty areas are made aware of concerns and follows up to ensure resolution.
- Schedules patient encounters and procedures to coordinate within and across providers in multiple specialties. Obtains and records required authorizations on electronic or manual scheduling systems to compile and distribute patient and staff schedules. Verifies patient demographics, insurance/payment and referral information for patient encounters.
- Collects and organizes medical records, information, materials and supplies required for admissions or encounters. Prepares requisitions and other standard forms as requested by clinician or supervisor.
- Participates in the development of training programs to update staff on department/hospital processes particularly as it relates to prior authorization for treatments, drugs and medical procedures.
- Trains, orients and cross-trains clinic staff in department systems, processes and terminology.
- Demonstrates high-level problem resolution skills. Provides assistance to other support staff in evaluating and resolving problems and issues.
- Serves as a resource on clinic/service/unit operations and procedures, payer and billing requirements and related matters.
Process Improvement
- Actively participates in and contributes to departmental and organizational initiatives and projects with a focus on continuous process improvement.
- Recommends and assists in implementing change in internal systems and procedures
Minimum Qualifications
Education:
- High School Diploma or GED
- 2 years of experience including healthcare or health insurance setting working with prior authorization.
Numbers & Facts
| Location | Boston, MA |
Skills
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