Full-time, 40 Hours/Week

8:30am - 5pm

Remote (Training onsite first 90 days)

Applicant must reside in OH or PA

Summary:

The Team Lead Specialty Authorization is responsible for overseeing the daily operations of the prior authorization team, focusing on specialty services such as pediatric surgeries, injections, and infusion therapies. This role ensures that the prior authorization process for these specialized treatments is efficient, accurate, and compliant with payer requirements. The team lead provides guidance, leadership, and training to specialists, collaborates with clinical staff, and ensures a seamless authorization process to prevent delays in care for our young patients.

Responsibilities:

1. Leadership & Oversight: Lead and supervise the team of prior authorization specialists to ensure smooth, accurate, and timely submission and follow-up of authorization requests for pediatric specialty services, including surgeries, injections, and infusion therapies.
2. Specialty Services Authorization Management: Oversee the authorization process for high-cost specialty treatments, including surgical procedures, intravenous injections, and biologic or infusion therapies, ensuring all required documentation is accurate and submitted to insurers on time.
3. Collaboration with Pediatric Specialists: Work closely with pediatric surgeons, infusion specialists, and other clinical teams to gather necessary clinical information for prior authorization requests and ensure that the treatments are medically necessary and supported by the appropriate documentation.
4. Training & Development: Provide ongoing training and development to the prior authorization team on best practices for specialty services, payer-specific requirements, and how to handle complex cases for surgeries, injections, and infusions.
5. Escalation & Problem Resolution: Act as the primary point of contact for any complex or escalated authorization issues related to specialty services. Work directly with insurance companies and healthcare providers to resolve authorization delays, denials, or issues in a timely manner.
6. Compliance & Regulatory Adherence: Stay updated on the latest payer policies, regulatory guidelines, and healthcare laws specific to pediatric surgeries, injections, and infusion treatments (including coverage under Medicaid, Medicare, private insurers, and specialty drug programs).
7. Data Tracking & Reporting: Maintain and report on key performance metrics for the prior authorization team, focusing on turnaround times, denial rates, and successful authorizations for specialty services. Provide actionable insights to leadership to improve processes.
8. Patient-Centered Communication: Ensure the team communicates effectively with parents and guardians about authorization status, any delays, and the next steps in the process, particularly for high-stakes treatments like surgeries or urgent infusion therapies.
9. Process Improvement: Identify areas for improvement in the authorization workflow, especially related to specialty services, and implement process enhancements to reduce delays, improve approval rates, and increase efficiency.
10. Interdepartmental Collaboration: Collaborate with the surgical scheduling team, infusion center, and pharmacy department to ensure timely approvals and scheduling of specialty services, minimizing delays in patient care.

Other information:

Technical Expertise

Full Time

FTE: 1.000000