About this role
At St. Luke’s, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke’s is truly a great place to work.
What You Can Expect:
Under limited supervision, the Specialty Financial Clearance Specialist Senior is responsible for securing prior authorizations for complex oncology treatments by demonstrating medical necessity to insurance payers. This role requires a strong understanding of oncology treatments, medical necessity guidelines, medical policies, and payer requirements to prevent treatment delays and ensure compliance. The Specialty Financial Clearance Specialist Senior will work closely with providers, insurance companies, pharmacies and patients to navigate the complex oncology treatment authorization process for chemotherapy, gene therapy, radiation, immunotherapy, oncology procedures, specialty labs, transplants, and other oncology-related services.
- Works closely with providers, pharmacy, clinical documentation integrity, coders, insurance companies, and other stakeholders to secure prior authorizations for complex and high dollar treatments such as chemotherapy, stem cell therapies, immunotherapies, targeted therapies, radiation therapies, oncology procedures and off label treatment plans. Applies and secures financial assistance for specialty labs.
- Possess a strong understanding of oncology treatments, medical necessity guidelines, clinical documentation, medical policies, and payer requirements to prevent treatment delays and ensure compliance.
- Submits, tracks, and follows up on authorization requests, prioritizing urgent cases as needed. Collaborates with insurance carrier's appeals teams and clinical teams to resolve denials and appeals efficiently, and coordinate peer-to-peer reviews. Escalates to external review to the State of Idaho when necessary.
- Communicates with insurance companies to clarify requirements, medical necessity indications and guidelines, and authorization requirements. Coordinates with clinical teams, insurance companies, Patient Financial Navigators to address insurance denials and manage appeals.
- Educates patients on insurance benefits, financial responsibility, non-covered services and required payer forms, treatment estimates and alternative coverage options.
- Provides updates on authorization status to oncologists, clinical teams, pharmacy, and Patient Financial Navigators.
- Maintains accurate records of authorization approvals, denials, and appeals.
- Ensures compliance with HIPAA, CMS regulations, and insurance guidelines.
- Stays updated on insurance policy changes, medical necessity guideline changes, prior authorization requirements, and oncology treatment protocols and informs colleagues of new information.
- May train and mentor others.
- Perform other duties as assigned.
Qualifications:
- Education: High School Diploma or equivalent
- Experience: 2 years relevant experience
At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Personify Health Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.
St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.
*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.