Infusion Prior Authorization Program Manager

It's more than a career, it's a calling.

MO-SSM Health Mission Hill

Worker Type:

Regular

Job Summary:

Serves as a subject matter expert and provides oversight to all pharmacy infusion centers system-wide, ensuring program integrity and optimization. Responsible for improvement and oversight of infusion prior authorizations and day-to-day management of initial and final denials through internal partnerships and payor-related initiatives, and in compliance with system policies and procedures.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES 

• Reviews all internal and external communication regarding payor contracts and formulary changes pertinent to infusion billing. Formulates impact statements and action plans needed by internal departments across the system. 
• Creates and maintains system education and best practices for state specific payors related to preferred infusion drugs, biosimilars, coding and payor documentation requirements for prior authorizations to outpace national trends and decrease initial and final denials. Resolves problems and rectifies inefficiencies related to infusion prior authorizations and denials. 
• Works closely with denials and quality leaders to identify root causes related to payor discrepancies and escalates issues through the appropriate channels for follow-up and resolution. Assists with the identification of training needs and coordinates with responsible parties to develop and conduct training programs, including on-the-job training. 
• Develops and analyzes reports and special studies to support system key performance indicators (KPIs) and operational results. 
• Monitors developments and trends inside and outside the organization that relate to assigned functions. 
• Shares expertise and assists with training, education, and communication to staff regarding updates to pharmacy infusion prior authorization policies and procedures.   
• Performs other duties as assigned. 

EDUCATION 

• Bachelor's degree

EXPERIENCE 

• Four years' experience in medical benefit prior authorizations, infusion operations, revenue cycle, managed care process improvement, or billing and coding in a healthcare setting 

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 

• None

Work Shift:

Day Shift (United States of America)

Employee

Department:

8753050033 Sys Pharm Access

Scheduled Weekly Hours:

40

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE). 

• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members. 

Explore All Benefits

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.