Job Description

Clearview Cancer Institute is north Alabama's leading cancer treatment facility. For over 30 years Clearview Cancer Institute has provided leading-edge treatment and compassionate care to those diagnosed with cancer or blood disorders. Clearview offers every service and amenity needed in an outpatient setting and our dedication to research and involvement in Phase I-IV clinical trials gives our patients the opportunity to receive potentially life-saving treatment options.

Why Join Us? We are looking for talented and highly-motivated individuals who demonstrate a natural desire to support the meaningful work of community oncologists and the patients we serve.

Job purpose: Oversee the process of obtaining prior authorization for hematology and oncology treatments from insurance companies, ensuring timely access to necessary medications and therapies while adhering to clinical guidelines and payer requirements, by managing a team of prior authorization specialist and coordinating with healthcare providers and insurance companies to navigate complex authorization processes.

Duties include:

Team Leadership:

• Manage a team of oncology prior authorization specialists, assigning tasks, monitoring performance and providing coaching to ensure efficient and accurate processing of authorization requests
• Develop and implement strategies to optimize team productivity and meet established performance metrics

Clinical Review and Decision Making

• Conduct comprehensive reviews of oncology/hematology treatment plans and patient medical records to determine appropriate prior authorization requests based on clinical guidelines, payer policies, and treatment protocols
• Analyze complex medical information to assess the clinical necessity of requested therapies and identify potential issues that may impact authorization approvals

Payer Management

• Stay updated on evolving payer policies and reimbursement guidelines, communicating changes to the team and adapting strategies accordingly

Patient Advocacy

• Collaborate with healthcare providers, nurses, and patients to address any prior authorization delays or denials, exploring appeals processes when necessary
• Ensure clear communication with patients regarding their prior authorization status

Data Analysis and Reporting

• Monitor and analyze prior authorization data to identify trends, areas of improvement, and potential cost savings opportunities
• Generate reports for leadership regarding prior authorization performance, including approval rates, turnaround times, and denials reasons

Compliance and Quality Assurance

• Ensure adherence to all relevant regulatory guidelines and compliance standards related to prior authorization processes
• Implement quality control measures to monitor accuracy and consistency of prior authorization submissions

Education/Experience

• Required bachelor’s degree in nursing, pharmacy, or healthcare administration
• Master’s degree preferred, but not required
• Extensive knowledge of oncology treatments, clinical guidelines and payer policies
• Proven experience in prior authorization management, particularly within the oncology setting
• Strong analytical and problem-solving skills to navigate complex patient cases and payer requirements
• Excellent communication and interpersonal skills to effectively collaborate with diverse stakeholders.

Working conditions:

This position works as part the business office of a busy outpatient oncology/hematology clinic overseeing the day-to-day operations of the prior authorization department.

Physical requirements:

This position requires that the employee be able to sit at a desk and work on a computer for up to eight hours a day

Direct reports

All Prior Authorization Specialist that are a part of the business office including float prior authorization specialist