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Authorization Specialist

1 month ago

Charlotte, North Carolina, United States Atrium Health Full time

Job Summary


As an Advanced Authorization Specialist at Atrium Health, you will play a critical role in obtaining complex authorizations for in-patient and out-patient services. This position requires a strong understanding of commercial and government payors, including coordination of benefits, authorization guidelines, pharmacy and medical benefit variances, and medical necessity policies. You will be responsible for reading and interpreting complex medical records to obtain authorizations for requested services and treatment plans. Effective 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. You will 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.

Key Responsibilities
  • Assess time-sensitive referral work queues to obtain highly complex authorizations, including IP/OP chemotherapy, radiology, and 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 mailboxes 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 online clinical requests for advanced 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).


Requirements

Bachelor's degree or 3 years of authorization experience required.


General knowledge and background in CPT and HCPCS coding.

Proficient with medical terminology and familiar with clinical considerations as they 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.


Work requires typing, filing, use of telephone, and sitting for prolonged periods of time.

Should be able to bend and lift up to 10lbs.