Senior Infusion Insurance and Prior Authorization Coordinator

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Senior Infusion Insurance and Prior Authorization Coordinator provides expert-level support to the infusion prior authorization team related to commercial vs government and oncology vs non-oncology therapy workflows. The position participates in implementing prior authorization workflows for new acquisition infusion centers and validating maintenance of prior authorization workflows at existing infusion centers.  This position 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, providers, and prior authorization coordinators. 

 

 

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

High school diploma or GED

At least 2 years of oncology infusion prior authorization experience

Knowledge of medication generic and biosimilar options as they relate to net financial outcomes

Critical thinking and decisive judgment on authorization matters with financial and operational significance

Excellent communication, organizational, and customer service skills and ability to work independently

Knowledge of major medical insurances and proficiency with payer portals and authorization tracking tools

Knowledge of HCPCS (J-codes) and ICD-10 (diagnosis codes) as they relate to medical and pharmacy benefits for infusion drugs

Familiarity with medical documentation such as H&Ps, diagnostic imaging, genetic testing, oncology staging

Ability to read and convert a prescription into an authorization request based on payer requirements

Ability to make drug option selections based on medical policies, medical necessity standards, and reimbursement methodologies

Ability to influence outcomes through judgement, escalation, and problem solving

 

Preferred qualification:

 

4 years of oncology infusion prior authorization experience

1-2 years progressive experience in pharmacy, medication authorizations, or revenue cycle operations involving independent decision making

Experience in Meditech, Mosaiq, Epic, Cerner and/or comparable oncology billing software

Associate’s or Bachelor’s degree in healthcare administration, business, or related field

Certification or studies in coding, medical terminology or revenue cycle processes

Pay Transparency

Prime Healthcare 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 $33,862.40 to $49,025.60 on an annualized basis. 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 founda