Manager Prior Authorization

Overview

Reporting to the Senior Manager, Clinical Services Authorizations, the Manager of Prior Authorization is responsible for managing, monitoring, and driving improvement in front-end revenue cycle functions related to authorization procurement processes. Specifically, this role oversees working with third-party payers, physicians, clinical teams, and departments within Finance and Revenue Cycle to ensure patients are financially cleared for services that the payers deem as requiring prior authorization. This includes the supervision, direction, and training of prior authorization supervisors and staff. The manager is responsible for data-driven effective and efficient workflows. The manager will frequently communicate with providers and patients with a key focus on developing and documenting processes and tracking statistics. Responsible for reviewing outpatient treatment plans for medical necessity in accordance with payer coverage guidelines. Applies medical knowledge and experience to all functions.

Located in Boston and the surrounding communities, Dana-Farber Cancer Institute is a leader in life changing breakthroughs in cancer research and patient care. We are united in our mission of conquering cancer, HIV/AIDS, and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

PRIMARY DUTIES AND RESPONSIBILITIES:

• Oversees third-party payer prior authorization for drugs provided in the clinic, imaging services, molecular pathology, and other clinical services that require prior authorization, including submission, appeals, and denials
• Monitors effective workflows that support advanced notice, short notice, and day-of notice of treatment
• Responsible for all aspects of leading an efficient and productive team, including: interviewing, hiring, training, directing work processes, managing performance, managing time and attendance, and recognizing and rewarding employees
• Proactively works to maintain staffing levels and reassigns work according to payer changes and organizational priorities, as appropriate
• Drives redesign efforts to support the clinical culture change in the timing of ordering clinical services, promoting that services are authorized before the patient’s appointment
• Maintains an excellent working knowledge of authorization requirements for all payers and state level regulatory guidelines for coverage and authorization for aligned services
• Maintains operational and financial policies and procedures
• Works collaboratively with other teams within Access Management, Patient Financial Services, Managed Care, and Partners eCare to ensure effective and efficient workflows as follows:
• Other teams within Access Management: ensure appropriate steps for the more complicated and entrepreneurial scenarios, such as off-label drug treatments, and radiopharmaceuticals for imaging treatment
• Managed Care: participates in activities associated with payer authorization requirements as necessary to direct staff impacted by changes and provide feedback to payers
• Patient Financial Services: supports other initiatives related to appropriate reimbursement, timely management of denials, including the goal of preventing denials
• Partners eCare: continues to design effective Epic tools, participating on support and design work groups
• Supports productivity and quality tracking and monitoring staff performance
• Supports day-to-day operations, managing and escalating complicated payer and patient issues
• Participate in professional organizations and educational opportunities
• Perform other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

• Knowledge of third-party payer rules and regulations
• Knowledge of medical terminology, pharmaceutical terminology, and practices
• Ability to effectively motivate, delegate, and supervise team
• Ability to effectively handle multiple priorities and projects independently
• Effective communication (listening, verbal, and written) skills
• Ability to effectively interface with all levels of management, to collaborate inter and intra departmentally in a highly matrixed organization with peers and clinicians across the organization, Partners eCare, and other cancer centers
• Strong organizational skills, problem solving, and time management skills
• Able to function independently in a fast-paced environment while managing multiple priorities
• Working knowledge of various software programs including Excel, Word, Patient billing software and Electronic Medical Record systems

MINIMUM JOB QUALIFICATIONS:

• Bachelor’s degree Required
• Nursing or related degree preferred
• 5 years of experience in Case Management, Utilization Review, and/or related healthcare experience; preferably with a focus in Oncology
• 1 year of experience managing or leading teams

SUPERVISORY RESPONSIBILITIES:

• Direct responsibility for two Supervisors and indirectly responsible for the employees of both team’s staff

At 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 committed to having faculty and staff who offer multifaceted experiences. Cancer knows no boundaries and when it comes to hiring the most dedicated and compassionate 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 characteristics protected by law.

Pay Transparency Statement

The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate’s relevant experience, skills and qualifications.

For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA).