Reporting to the Drug Authorization Supervisor, the Drug Authorization Specialist is responsible for independently managing all work related to drug authorizations for all injectable drug treatment plans ordered by Dana Farber Cancer Institute providers. 

Working in a fast-paced, high-volume, dynamic environment, the Drug Authorization Specialist will demonstrate strong understanding of payer coverage policies, applying appropriate payer guidelines to all aspects of drug prior authorization work. The Specialist will leverage their strong understanding of medical terminology and physiology to retrieve the appropriate clinical documents (e.g., progress notes, lab values, scan results) from within the electronic medical record (EMR). The Drug Authorization Specialist will create accurate, thorough, concise, prior authorization requests to all payers.

Located in Boston and the surrounding communities, Dana-Farber Cancer Institute brings together world renowned clinicians, innovative researchers and dedicated professionals, allies in the common mission of conquering cancer, HIV/AIDS and related diseases. Combining extremely talented people with the best technologies in a genuinely positive environment, we provide compassionate and comprehensive care to patients of all ages; we conduct research that advances treatment; we educate tomorrow's physician/researchers; we reach out to underserved members of our community; and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

PRIMARY DUTIES AND RESPONSIBILITIES:

• Review and monitor the drug authorization work queue and independently identifies and prioritizes patient treatment/therapy plans that require prior authorization.
• Reprioritizes work to respond to clinically urgent treatment and therapy plans and produces high quality work under pressure.
• Verifies insurance eligibility and benefits, utilizing automated eligibility systems, payer portals, and/or telephone communication.
• Assist patients with resolving insurance related issues while prior to initiating treatment.
• Prepares and completes payer-specific prior authorization request forms, interprets medical policy criteria, and applies appropriate guidelines to prior authorization requests.
• Reviews and comprehends patient progress notes, lab reports, infusion summaries, imaging reports, and plan of care. Identifies appropriate medical documentation that satisfies payer medical policy criteria.
• Responds to health plan-reviewed prior authorization requests that do not meet initial policy criteria. Works with the health plan to resolve issues and/or coordinates appropriate provider-to-health plan interventions (e.g., peer-to-peer discussions, letters of medical necessity, provider-initiated appeals, etc.).
• Manages prior authorization reports to ensure appropriate drug dispenses are appropriately authorized and followed-up on.
• Monitors and reports changes in payer prior authorization requirements to update and maintain prior authorization tools and spreadsheets.
• Completes appropriate post-claim denial follow-up to overturn drug-related prior authorization claim denials.
• Maintains digital archiving of prior authorizations to support post-claim denial workflows.
• Assists with the training of new staff and performs other work duties and projects as assigned.

Minimum Education:

• High School diploma or equivalent required; Bachelor’s degree with a science related background preferred.

Minimum Experience:

• 1 year of relevant work experience in a hospital or ambulatory setting, including hospital/physician office work, prior authorization, financial counseling and billing experience preferred. Other relevant experiences include but are not limited to healthcare/business administration, health insurance, medical policy review and/or pharmacy. Previous experience with case management, utilization review or prior authorization preferred.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

• Strong analytical and problem-solving skills.
• Demonstrated knowledge of third-party payer rules and regulations.
• Ability to function independently and prioritize work within established policies. 
• Ability to work closely and effectively with colleagues across the organization including clinical staff.
• Ability to work with sensitive patient information and maintain confidentiality.
• Ability to prioritize and meet pre-determined deadlines.
• Excellent customer service and communication skills, both written and verbal. 
• Ability to use good judgment, tact, and sensitivity.
• Ability to function in a fast paced, highly demanding environment.

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 equally committed to diversifying our faculty and staff.  Cancer knows no boundaries and when it comes to hiring the most dedicated and diverse 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 groups as protected by law.