Senior Central Prior Authorization Analyst at Adventist Health

Roseville, California, United States -

Full Time

Start Date

Immediate

Expiry Date

24 Sep, 26

Salary

40.33

Posted On

26 Jun, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Prior Authorization, Infusion Site-of-Care Strategy, Revenue Cycle Management, Benefit Investigation, Denials Resolution, Epic EMR, Pharmacy Access Optimization, Financial Clearance, Payer Policy Analysis, Clinical Appropriateness Evaluation, Stakeholder Management, Process Improvement, Patient Advocacy, Regulatory Compliance, Data Analytics, Mentorship

Industry

Hospitals and Health Care

Description

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary: Serves as a subject matter expert and strategic partner in optimizing infusion site-of-care decisions, pharmacy access, and revenue integrity. This role operates with a high degree of autonomy and is responsible not only for executing complex workflows, but also for leading process improvement initiatives, influencing cross-functional stakeholders, and driving measurable financial and operational outcomes. In coordination with financial clearance, pharmacy, and clinical teams, this role evaluates and determines the most appropriate infusion site of care based on clinical appropriateness, payer policy, and financial impact. The Senior Analyst leverages advanced analytics, deep payer knowledge, and system-wide insights to optimize patient access, minimize denials, and maximize reimbursement across the continuum of care. Job Requirements: Education and Work Experience: * High School Education/GED or equivalent: Preferred * Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred * Six years' of progressive experience in infusion, specialty pharmacy, revenue cycle, or related healthcare operations: Required * Experience in Epic or similar electronic medical records (EMR) platforms: Preferred * Knowledge of healthcare insurance, prior authorization and/or coding: Preferred Licenses/Certifications: * State Pharmacy Technician license (CA, OR, &/or HI): Preferred * Pharmaceutical Technician Board certification: Preferred * Advanced certification (e.g., CHRI, CRCR, or 340B ACE): Preferred * Pharmaceutical Technician Board certification: Preferred Essential Functions: * Serves as the lead subject matter expert for infusion site-of-care strategy, payer requirements, and pharmacy benefit optimization. Independently evaluate complex patient cases to determine optimal infusion site of care, balancing clinical appropriateness, payer constraints, and financial impact. Lead coordination with central financial clearance, pharmacy operations, and clinical teams to ensure seamless referral routing across home infusion, ambulatory infusion, and alternate care sites. * Oversee and perform advanced benefit investigation, prior authorization strategy, and denials resolution, including escalation of high-risk or high-dollar cases. Identify trends in denials, payer behavior, and workflow inefficiencies; develop and implement data-driven process improvements. Act as a strategic liaison between pharmacy, revenue cycle, and clinical operations to enhance patient access and optimize reimbursement. * Provide guidance, training, and mentorship to analysts and technicians; serve as an escalation point for complex issues. Drive standardization of workflows, documentation practices, and referral processes across the health system. Promote and articulate the value of the infusion hub model and site-of-care strategy to internal and external stakeholders. Build and maintain strong relationships with physicians, clinic leadership, pharmacy teams, and payers. * Act as a financial advocate for patients, leveraging manufacturer assistance programs, foundations, and alternative funding sources. Participate in or lead cross-functional projects, pilots, and system implementations related to pharmacy services and revenue optimization. Ensure compliance with regulatory requirements (e.g., CMS, payer policies, 340B considerations where applicable). * Provide coverage support while maintaining oversight of broader program performance and service delivery. Assesses, develops, and recommends the best method of providing ambulatory infusion pharmacy services to support patients based on health system guidance. Develops and maintains close relationships with clinic staff, physician, pharmacy and other hospital contacts. Independently, and working hand in hand with client authorization resources, facilitates benefits verification and prior authorizations services for infusion site of care patients. * Performs other job-related duties as assigned. Organizational Requirements: Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

Responsibilities

Acts as a subject matter expert to optimize infusion site-of-care decisions, pharmacy access, and revenue integrity. Leads process improvement initiatives and coordinates with clinical and financial teams to minimize denials and maximize reimbursement.