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Director Prior Authorization Jobs (NOW HIRING)

Dana-Farber Cancer Institute

The Prior Authorization Supervisor will have expert knowledge of third-party payer medical policies and procedures and facilitate appropriate provider-to-payer medical director discussions. He/She ...

Medix

Prior Authorization Coordinator

Chandler, AZ · On-site

$19 - $21/hr

High-volume prior authorization experience and patient care coordination. * Manage front desk ... providing direct patient care, accessing medical and confidential records, accessing and ...

WomanCare Centers

Prior Authorization Nurse

Norfolk, VA · On-site

$25 - $31/hr

... as directed by the provider. * Maintain accurate and timely documentation of all prior authorization activities in the electronic health record (EHR). * Process medication refill requests as ...

NHSHP

$249 - $373/hr

Prior authorization, utilization management and claims review cases for patients * Provide ... Work with medical director teams focusing on inpatient care management, clinical coverage review ...

Jobless

WI · On-site

$52 - $75/hr

Reporting to the Director of Revenue Cycle, this position is responsible for obtaining prior authorizations and pre-certifications for procedures and medications, coordinating the scheduling and re ...

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Director Prior Authorization information

What is the difference between Director Prior Authorization vs Medical Claims Supervisor?

AspectDirector Prior AuthorizationMedical Claims Supervisor
Required CredentialsBachelor's degree, industry certifications often preferredBachelor's degree, relevant certifications beneficial
Work EnvironmentHealthcare organizations, insurance companiesHealthcare providers, insurance companies
Employer & Industry UsageUsed in health insurance and healthcare managementCommon in healthcare administration and insurance claims processing
Primary FocusReviewing and approving prior authorization requestsOverseeing claims processing and ensuring accuracy

The main difference is that the Director Prior Authorization focuses on managing the approval process for medical procedures before they occur, while the Medical Claims Supervisor oversees the processing and accuracy of claims after services are provided. Both roles require healthcare knowledge, but their responsibilities and workflows differ significantly.

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Prior Authorization Supervisor

Dana-Farber Cancer Institute

On-site, Remote

Full-time

Re-posted 23 days ago

Dana-Farber Cancer Institute rating

8.3

Company rating: 8.3 out of 10

Based on 21 frontline employees who took The Breakroom Quiz

Job description

Reporting to the Manager of Prior Authorization, the Prior Authorization Supervisor is responsible for managing the operational workflows and staff obtaining drug and laboratory procedure prior authorizations from third-party payers. This work will primarily address on-/off-label drugs and molecular pathology procedures provided in the outpatient hospital setting.
A key focus of the Prior Authorization Supervisor will be to apply appropriate medical knowledge to all functions of the prior authorization work. He/She will oversee and ensure staff applies appropriate medical knowledge and training. The Prior Authorization Supervisor will assist with prior authorization medical necessity inquiries, with a primary focus on drug and laboratory prior authorizations.
Prior Authorization work requires its staff to serve as liaisons between the clinical team and third-party payers. The Prior Authorization Supervisor will demonstrate a strong ability to collaborate with these key stakeholders. He/She will be required to understand and discuss clinical relevance of treatment plans with providers and complete research publications reviews independently. The Prior Authorization Supervisor will have expert knowledge of third-party payer medical policies and procedures and facilitate appropriate provider-to-payer medical director discussions. He/She will apply these skills to his/her management of the prior authorization staff.
Located in Boston and the surrounding communities, Dana-Farber Cancer Institute is a leader in life changing breakthroughs in cancer research and patient care. We are united in our mission of conquering cancer, HIV/AIDS, and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.
PRIMARY DUTIES AND RESPONSIBILITIES:
  • Understands and values the Dana-Farber Cancer Institute mission and applies it to all prior authorization processes.
  • Oversees the daily on-label drug prior authorization operations related to outpatient, clinic-infused drugs and other drug infusions within the scope of the Dana-Farber Cancer Institute Access Management Department.
  • Assists staff with complicated clinical or administrative on-label drug cases with the goal of resolving the prior authorization issue before rendering the service.
  • Oversees clinical staff members responsible for off-label chemotherapy regimen prior authorization requests. Works closely with pharmacists, clinicians, and other access management teams, to obtain appropriate financial clearance prior to treatment. Understands and meets treatment deadlines appropriately.
  • Assists clinical staff with complicated clinical or administrative off-label chemotherapy regimen requests with the goal of resolving coverage issues. Escalates complicated administrative cases to Manager of Prior Authorization or Access Management Director.
  • Assists in the design and implementation of new molecular pathology prior authorization workflows.
  • Oversees the daily molecular pathology prior authorization operations for Dana-Farber Cancer Institute administered services.
  • Assists staff with complicated clinical or administrative molecular pathology cases with the goal of resolving the prior authorization issue before rendering services.
  • Discusses complex medical necessity cases in all aspects of the prior authorization work (on-label drug, off-label drug, laboratory testing, and others as assigned) with attending physicians. Understands a case's complex medical necessity and communicates appropriate medical information to the third-party payer. Completes medical science literature searches and/or coordinates appropriate provider-to-payer medical director discussions. Collaborates with attending physicians on treatment alternatives when medical necessity coverage denials cannot be overturned. Appropriately escalates complex cases to Manager of Prior Authorizations or Access Management Director.
  • Monitors payer policy changes related to drug and molecular pathology prior authorizations. Takes appropriate actions to ensure future services are appropriately identified prior to rendering services.
  • Develops and maintains appropriate tools to support drug and molecular pathology prior authorization teams.
  • Reviews drug prior authorization workflows, identifies gaps, and implements enhancements to improve processes. Communicates issues to Manager of Prior Authorization.
  • Attends regular meetings with the Access Management and/or other Revenue Cycle Departments to discuss revenue cycle issues, implement improvements, and disseminate information appropriately.
  • Oversees the daily prior authorization denial workflows including retro authorizations, coordinating peer-to-peer discussions, and writing/filing appeals to the third-party payer.
  • Assists with complex prior authorization denials and denial projects. Escalates issues to Manager of Prior Authorization or Access Management Director accordingly.
  • Maintains standard operating procedures for the prior authorization team.
  • Monitors staffing productivity and delegates daily work accordingly.
  • Ensures adequate staffing coverage for required duties.
  • Performs other duties as assigned by Manager of Prior Authorization and remains compliant with all departmental and institutional policies.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:
  • Demonstrates strong ability to train, develop, and oversee clinical and non-clinical staff.
  • Demonstrates strong leadership and teamwork skills
  • Self-starter with strong analytical, problem solving skills
  • Highly organized, able to multi-task and prioritize work quickly and effectively
  • Performs well in high-pressure situations
  • Superior written and verbal communication skills, knowledge of Microsoft Office products, and technical computing skills
  • Strong clinical knowledge with an ability to apply it appropriately and effectively, oncology knowledge a plus.

MINIMUM JOB QUALIFICATIONS:
  • Bachelor's degree in Nursing required.
  • Licensed as a Registered Nurse in the Commonwealth of Massachusetts preferred.
  • Minimum 3 years in a Case Management, Utilization Review, and/or related healthcare experience
  • 2-3 years of supervisory experience preferred
  • Prior patient access experience, revenue cycle experience, and/or payer rules and regulations knowledge required.

SUPERVISORY RESPONSIBILITIES:
  • Supervise up to fifteen (15) direct reports.

PATIENT CONTACT:
  • No

At Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are committed to having faculty and staff who offer multifaceted experiences. Cancer knows no boundaries and when it comes to hiring the most dedicated and compassionate professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.
Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law.
EEO Poster
Pay Transparency Statement
The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate's relevant experience, skills and qualifications.
For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA).
$96,500.00 - $109,100.00

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About Dana-Farber Cancer Institute

Sourced by ZipRecruiter

Dana-Farber Cancer Institute is a leader in life changing breakthroughs in cancer research and patient care. We are united in our mission of conquering cancer, HIV/AIDS and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

Industry

Health care and social assistance

Company size

1,001 - 5,000 Employees

Headquarters location

Boston, MA, US

Year founded

1947

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