Clinical Insurance Reviewer
About The Position
Under general supervision, the Clinical Insurance Reviewer reviews chemotherapy regimens according to reimbursement guidelines and obtains necessary pre-certifications and exceptions to avoid delays in treatment reimbursement. The role researches denied services and alternative resources for payment, supports the US Oncology Compliance Program, and adheres to its Code of Ethics and Business Standards. The reviewer assesses medical necessity and documentation for chemotherapy treatments, communicates payer restrictions and requirements to clinical staff, and provides feedback to physicians and management about pathway documentation and coverage issues. The role secures chemotherapy authorizations, advocates for patients by helping address reimbursement questions, and researches financial, pharmaceutical, and community resources when services are not covered. It also maintains knowledge of payer authorization requirements and applicable regulatory and privacy guidelines, updates coding and payer information for clinical staff, tracks pathways, and performs other business office duties as needed.
Requirements
- High school degree or equivalent.
- At least three years of medical insurance verification and authorization experience.
- Maintain confidentiality and comply with applicable patient-record laws and guidelines.
Nice To Haves
- Associate degree in Healthcare.
- LPN state license and registration.
Responsibilities
- Review, process, and audit the medical necessity of each patient chemotherapy treatment and documentation of the regimen relative to pathway adherence.
- Communicate insurance-plan restrictions and special requirements to nursing and medical staff.
- Provide physicians and management with prompt feedback regarding pathway documentation issues and payer issues involving non-covered chemotherapy drugs.
- Update coding and payer guidelines for clinical staff, track pathways, and perform other business office functions as needed.
- Obtain insurance authorization and pre-certification specifically for chemotherapy services.
- Act as a patient advocate and liaison between patients and payers to answer reimbursement questions and help avoid insurance delays.
- Research additional or alternative resources for non-covered chemotherapy services to prevent payment denials.
- Provide patients with contact lists for community resources, including special programs, drugs and pharmaceutical supplies, and financial resources.
- Maintain working knowledge of chemotherapy authorization requirements for all payers and state and federal coverage and authorization regulations.
- Protect patient-record confidentiality and comply with applicable state and federal laws and guidelines.
- Perform other duties as requested or assigned.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
