RN Infusion Clinical Coordinator

Company: CHI Franciscan
Location: Tacoma
Posted on: October 11, 2021

Job Description:

Overview

• Competitive starting wages (DOE) and training to grow within the company
• Paid Time Off (PTO)
• Health/Dental/Vision Insurance
• Flexible health spending accounts (FSA)
• Matching 401(k) and 457(b) Retirement Programs
• Tuition Assistance for career growth and development
• Care@Work premium account for additional support with children, pets, dependent adults, and household needs
• Employee Assistance Program (EAP) for you and your family
• Voluntary Protection: Group Accident, Critical Illness, and Identify Theft 
• Adoption Assistance
• Wellness Program

Job Summary:

This role will be based at St. Joseph Medical Center OP Oncology/Infusion clinic. The position is responsible for serving as liaison between the revenue cycle/prior authorization team, clinic staff, provider’s office(s) and pharmacy team to facilitate and troubleshoot the timely submission of prior authorization requests, including urgent and denied referrals/authorizations.  An incumbent works to assure optimal reimbursement for high cost clinical regimens, cancer medications, and other infusion therapies while working to eliminate barriers that might otherwise adversely impact patient care/outcomes.  Prevention of delays in treatment authorization is a primary focus.

The duties include representing Virginia Mason Franciscan Health (VMFH) for provider prior authorization and assuring that all authorization requirements are completed in accordance with the payer’s criteria, in a timely manner, prior to services being rendered.  An incumbent performs clinical reviews, collects clinical information needed/requested by the payer and promotes the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. 

Incumbents are also accountable for keeping abreast of new/changing regulatory requirements impacting matters within designated scope of responsibility; maintaining current knowledge of departmental policies/standards/procedures, Joint Commission standards, new clinical procedures/processes, patient safety goals, core measure quality indicators and other issues/requirements impacting matters within assigned scope of responsibility; ensuring these factors are considered and integrated into clinical, performance improvement and education activities.

Essential Job Duties:

• Coordinates processes to assure that prior authorizations and referrals are addressed in a timely manner; supports clinical authorization team with requests for required documentation to facilitate timely authorization/authorized referral approval; coordinates and/or gathers missing or additional documentation needed for authorization submittals; provides necessary documentation to provider to submit for appeals.
• Provides requisite documentation to provider for completion of peer-to-peer reviews; facilitates timely completion of peer-to-peer reviews and appeals by serving as liaison between provider and authorization teams; follows up with provider if peer-to-peer review is not completed by established timeframe.
• Serves as liaison between insurance companies, financial clearance/authorization teams, clinics, provider/provider offices and pharmacy team; serves as liaison with other stakeholders requesting authorization for coverage or to discuss a denial of a provider-administered pre-authorization request.
• Reviews physician orders for specific patient treatment; in collaboration with the Financial Clearance Team, identifies patients with no or insufficient insurance which is detrimental to optimal patient care/outcomes; seeks to identify resources to mitigate the issue.
• Collaborates with Pharmacy team to identify resources for obtaining insurance/medication(s)/co-insurance support for prescribed treatment regimens (e.g. availability/eligibility for pharmaceutical company-sponsored medication assistance program for uninsured, under-insured or indigent) to provide financial assistance to help patients access drugs.
• Coordinates the authorization appeal process for procedures that are deemed not medically necessary; refers cases requiring additional clinical review to appropriate stakeholders to ensure all necessary approvals are obtained prior to care.
• Expedites urgent referrals in accordance with Urgent Authorization workflow and coordinates with financial clearance and/or clinical authorization team to assure authorization is in place; triages clinical situations, within scope of practice, where urgent care is needed but prior authorization hasn’t yet been approved.
• Addresses, within scope of position, denial issues such improper coding, missing clinical documentation to meet medical necessity and more complicated authorization-related errors.
• Advises physician when authorization is denied; works with physician to revise authorization submission (if clinically appropriate, support a peer-to-peer review, work with Pharmacy to obtain free medication or change the medication(s) to a clinically indicated alternative regimen.  
• Accesses internal/external systems to gather clinical documentation for providers, insurers and/or other interested parties; applies considerable knowledge of cancer and non-cancer treatment regimens, treatments and drugs to facilitate timely and optimal patient care.
• Monitors and maintains awareness of patient status/outcomes within scope of position; audits patient records and evaluates results achieved in relation to care objectives.
• Maintains ongoing communication with patients to check progress through the course of their treatment to help assure their needs are being met; answers questions relating to insurance/billing-related questions; identifies actual and/or potential problems/concerns and intervenes, within scope of position, in a timely and appropriate manner.
• Provides support to the patient/family during difficult decision-making periods, empowering them to make informed treatment decisions; advocates for patient/family in decision-making discussions, preserving and protecting patient autonomy, dignity, rights and cultural beliefs.
• Confers directly with healthcare providers and other stakeholders regarding prior authorization and/or related case management issues/problems; maintains contact with patient’s clinician and advises other care providers of developments in prior authorization issues when indicated.
• Keeps abreast of trends, developments and regulatory requirements impacting matters within designated scope of responsibility.
• Completes all required documentation in accordance with VMFH standards and procedures; maintains timely ongoing tracking and appropriate documentation of prior authorization/referrals; collaborates with clinical department staff, pharmacy and Conifer team so appropriate authorization for treatment is obtained before proceeding with patient care.
• Performs related duties as required.

Minimum Work Experience/Education Requirements:

Bachelor’s degree in Nursing or other related discipline, graduation from an accredited school of nursing, and three years of related professional nursing work experience in the clinical focus area that demonstrates the attainment of the requisite job knowledge, skills and abilities. 

Additional equivalent qualifying work experience that demonstrates attainment of the requisite job knowledge/abilities may be substituted for two years of the degree requirement (Associate’s degree required).

Licensure/Certification Requirements:

Current licensure by the Washington State Board of Nursing is required.

Keywords: CHI Franciscan, Tacoma , RN Infusion Clinical Coordinator, Other , Tacoma, Washington