Infusion Insurance and Prior Authorization Representative

Responsibilities

The Infusion Insurance and Prior Authorization Coordinator 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, and providers.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. High school diploma or GED2. Critical thinking and decisive judgment on authorization matters with financial and operational significance3. Excellent communication, organizational, and customer service skills and ability to work independently4. Knowledge of major medical insurances and proficiency with payer portals and authorization tracking tools5. Knowledge of HCPCS (J-codes) and ICD-10 (diagnosis codes) as they relate to medical and pharmacy benefits for infusion drugs6. Familiarity with medical documentation such as H&Ps, diagnostic imaging, genetic testing, oncology staging7. Ability to read and convert a prescription into an authorization request based on payer requirements8. Ability to interpret medical policies, medical necessity standards, and reimbursement methodologies9. Ability to influence outcomes through judgement, escalation, and problem solving

Preferred qualification:

1. 1-2 years progressive experience in pharmacy, medication authorizations, or revenue cycle operations involving independent decision making2. Associate’s or Bachelor’s degree in healthcare administration, business, or related field

Pay Transparency

St. Mary's Hospital - Kankakee 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 $15.50 to $22.45. 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/

Employment Status

Shift

Equal Employment Opportunity

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