Coordinator I - Research Infusion Authorization

Responsibilities: The Research Infusion Authorization Coordinator I position within the HonorHealth Research Institute initiates and obtains prior authorizations for clinical trials and continuing care infusion/chemotherapy and supportive drugs, prescription drugs, DME, and radiology. Working closely with clinical and administrative teams to prevent denials by ensuring medical necessity and obtaining prior authorizations promptly. Coordinating the approval process for white bag, manufacturer assistance and compassionate use medication. Optimizing processes to protect the organization's financial goals and patient liability, which involves organizing workflow, tracking critical information, and contacting physicians and pharmacy staff for required documentation. Verifying insurance eligibility and benefits, documenting the EMR in detail, and adhering to all third-party payer requirements. Consults with patients regarding clinical trial financial paperwork. Provides and assists with information concerning basic financial assistance through the HonorHealth Network.

Essential Functions: Performs tasks related to the management of prior authorization for patients served by HonorHealth Research Institute. Reviews medical records for submission to insurances, abstracting information from the patient medical records pertaining to patient treatments, procedures and guidelines as required. Review's patient treatment plan including frequency and dosage prior to treatment and reviews the applicable payer reimbursement criteria to ensure that the specific payer's medical necessity criteria is met. Obtains approval, authorization and or predetermination for all chemotherapy and non-chemotherapy infusion drugs, pharmacy, DME and radiology prior to treatment. Communicates clearly, effectively, and respectfully with patients, physicians, infusion staff and other personnel within the organization. Provide results of the authorizations and or predeterminations. Communicates payer criteria to providers and or patients as requested. Initiates appeals and schedules peer to peer consultations as needed for denials. Provides formulary assistance for clinic through evaluating payer requirements. Assists in the maintenance and communication of changing payer and pharmaceutical information specific to coordination of patient needs, benefits, and medical necessity. Enters complete and accurate notes regarding benefits, authorization, and predeterminations. Responsible for coordination of outpatient infusion site replacement /free medication applications for those patients needing financial assistance, as well as ordering medication and refills including setting up delivery to pharmacy site and tracking shipments. Must work closely with pharmacy personnel to confirm delivery and account for packing slips. Works to screen and track applications to pharmaceutical manufacturers for medication replacement for off label drug use. Must communicate with patients and providers on status of applications. Must also be in communication with medical staff to verify if treatment plan is still accurate prior to ordering medications. Must coordinate the ordering of additional doses with pharmacy personnel. Must also work closely with billing department to maintain accurate account notes to ensure correct billing. Verifies patients' insurance eligibility and coverage, confirms authorization status to avoid non-compliance and penalties to the patient, health system and physician. Collaborates with staff members to ensure patient status is correct and documentation is provided to insurances as needed. Ability to discuss self-pay policies for non-covered services. Conducts financial consult with patients enrolled in a clinical trial, reviewing sponsor payments, travel reimbursement, and collection of all required documentation. Reconciles reimbursement forms and receipts, inputs data into specific platforms and reimbursement portals. Collaborates with accounting department to confirm accuracy and distribution of reimbursement. Review the Phil's Fund Charity program to qualified patients while guiding them through the enrollment process and entering data into the funding portal. Conducts outbound and inbound communications with patients, responding to questions and concerns, and facilitate problem-solving. Perform data entry of actions and responses and enter notes into EMR system regarding prior authorizations and benefits. Verify patients' insurance eligibility and coverage, ensuring correct patient status and documentation. Discuss and assist with basic financial assistance and self-pay policies for non-covered services. Other duties as assigned. Education High School Diploma or GED Required Technical Training Diploma/Degree Vocational/Technical training 2 years of college or technical school Preferred Experience 1 year, Prior authorization experience Required 2 years, of medical experience in a registration related area or scheduling of employees, or coding; including but not mandatory – medical terminology Preferred 2 years, Medical/Dental/Insurance office experience Preferred License and Certifications