High-Cost Therapy Liaison RN

Job Title & Specialty Area: High-Cost Therapy Liaison RN 

Department: Utilization Management 

Location: Children's Health- Trinity Towers

Shift: Monday through Friday 8:00a to 5:00p

Job Type: Remote, but there will be an expectation to come onsite 2x a month as well as any events that will require onsite attendance 

Why Children's Health?

At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
A specialized clinical and reimbursement-focused role responsible for coordinating and managing complex, high-cost medication authorizations to support timely patient access to therapy. Leveraging advanced clinical knowledge and expertise in specialty medications, payer policies, medical necessity requirements, and FDA-approved indications, this role conducts comprehensive reviews of clinical documentation to develop and support authorization, denial, and appeal submissions.Working collaboratively with providers, pharmacists, clinical teams, payers, and manufacturers, the High-Cost Therapy Liaison RN serves as a subject matter expert on high-cost therapies and complex authorization requirements. This position applies critical thinking and nursing judgment to navigate coverage barriers, interpret evolving payer guidelines, identify approval risks, and recommend strategies to optimize authorization outcomes. The role requires a high level of strategic problem-solving abilities, attention to detail, and specialized knowledge of reimbursement processes to ensure compliant, accurate, and efficient access to high-cost and specialty medications.

Responsibilities:
* Serve as a subject matter expert on specialty and high-cost therapies by interpreting payer policies, medical necessity criteria, clinical guidelines, FDA-approved indications, and reimbursement requirements to support coverage determinations and authorization outcomes
* Review and evaluate complex clinical documentation, including medical records, treatment history, laboratory results, and diagnostic information, to support high-cost medication authorization requests
* Collaborate with physicians, pharmacists, and clinical staff to obtain and develop supporting documentation, including letters of medical necessity, treatment plans, and evidence-based medical research publications.
* Develop and maintain relationships with pharmaceutical manufacturers to ensure timely authorization and administration of medication therapies.
* Coordinate and manage prior authorizations for specialty, infusion, and other high-cost therapies across multiple payer types to ensure timely patient access to treatment and accurate payment of claims in support of organizational goals.
* Supports the coordination of payer, financial, and operational processes related to high-cost therapies to ensure appropriate access and reimbursement.
* Utilize clinical judgment and critical thinking to assess complex cases, resolve non-routine authorization challenges, and escalate issues to other stakeholders to assist with resolution as appropriate
* Manage authorization denials, reconsideration, and appeal activities by reviewing payer determinations, coordinating peer-to-peer discussions, obtaining supporting clinical documentation, and facilitating timely submissions.
* Maintain accurate and compliant documentation of authorization activities, payer communications, determinations, and appeal outcomes within designated systems.
* Maintains advanced knowledge of specialty medications, reimbursement practices, payer policies, and regulatory requirements affecting high-cost therapies.
* Develop and maintain relationships with pharmaceutical manufacturers to ensure timely authorization and administration of medication therapies.
* Acts as a preceptor and mentor for new employees, ensuring a smooth onboarding experience through education on workflows, policies, procedures, and departmental
* Maintains performance in accordance with departmental productivity and quality metrics, ensuring timely and accurate authorization processing to support continuity of care and maximize claim reimbursement.
* Educates providers and office staff on payer requirements, formulary restrictions, and authorization processes. and reimbursement considerations to improve access to therapy.

 How You’ll Be Successful:

WORK EXPERIENCE
* At least 2 years clinical or healthcare-related experience in acute care, ambulatory care, specialty pharmacy, infusion services, case management, utilization management, and/or population health. Required and
* At least 1 year experience in medication prior authorizations, specialty medications, high-cost therapies, reimbursement activities, or payer-related functions involving commercial, Medicare, Medicaid, and other insurance coverage determinations, denials, and appeals. Required

EDUCATION
* BSN in Nursing Essential BSN
* Masters Degree Preferred

LICENSES AND CERTIFICATIONS
* Registered Nurse-1N-RN Essential Current license to practice professional nursing in the State of Texas - Time Frame: Upon Hire

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

 Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement 

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.