Job Summary: The Authorization Specialist II ensures accuracy of insurance information and obtains prior authorization and predetermination requirements for non-oncology infusions, oncology infusions, and radiation oncology. This role navigates highly detailed processes including treatment plans, National Comprehensive Cancer Network (NCCN) guidelines, medical necessity reviews, authorization submissions and follow-up care. The Authorization Specialist II maintains exceptional customer service, promotes the teamwork, and reflects the goals, values, and mission of the health system.

Minimum Education: High School Diploma or GED.

Licensure, Registration and/or Certification: None.

Work Experience: Minimum 2 years of benefits verification or authorization experience or 3 years of pre-registration experience. Post -secondary education may be substituted for 2 years of experience.

Knowledge, Skills and Abilities: Basic healthcare knowledge and insurance terminology including medical billing and insurance follow-up processes. PC and basic software skills. Proven keyboard skills with the ability to type 75 WPM. Excellent oral and verbal communication skills. Ability to navigate insurance websites to access patient eligibility and payment information. Ability to organize and prioritize work and the ability to be detail oriented. Ability to interact with physicians, physician offices and all levels of team members within the health system.

Essential Functions and Responsibilities: Monitors patient, referrals, and denials work queues to determine encounters that require pre-registration, verification, authorization, or corrections to ensure proper billing. Works encounters according to assignment and consistently meets daily and weekly productivity goals. Evaluates physician orders and pre-screens for medical necessity; notes frequency and duration of treatment plan and communicates directly with ordering provider or clinical staff to facilitate order revisions as indicated. Reviews clinical documentation for Current Procedural Terminology (CPT) and diagnosis code information to support authorization and precertification according to payer guidelines. Monitors, reviews, and processes authorizations and validates the requests are accurate, within the required timeline, and in compliance with the applicable insurance guidelines. Consults with pharmacy team members regarding provider ordered drugs in relation to payer preference to identify appropriate codes for authorization submission and to establish the appropriateness of the treatment regimen in alignment with NCCN and payer guidelines. Confers with pharmacy or clinical partners to facilitate additional information when required by payer. Coordinates with patient, referring physician's office, referring location, scheduled service area, financial counselors, case manager, and others, as appropriate to obtain additional information or provide information on patient financial status. Documents pertinent information and efforts in computer system based upon department documentation standards. Protects the privacy and security of patient health information to ensure that confidentiality is maintained.

Decision Making: Independent judgement in planning sequence of operations and making minor decisions in a complex technical or professional field.

Working Relationships: Works directly with patients and/or customers. Works with internal and/or external customers via telephone or face to face interaction. Works with other healthcare professionals and staff.

Special Job Dimensions: None.

Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

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