Insurance Clinical Reviewer

The US Oncology Network•Fort Worth, TX

4h•Onsite

About The Position

The US Oncology Network is seeking a Clinical Insurance Reviewer to join the team at Texas Oncology. This full-time position will support the Central Imagine Scheduling Department at the 500 South Henderson Suite 400 clinic in Fort Worth, Texas, with a typical work week of Monday through Friday, 8:30a- 5:00p. The role can be filled at either a Level 1 or Sr level, depending on the candidate's work experience. Texas Oncology, part of The US Oncology Network, is the largest community oncology provider in the country, with approximately 530 providers across 280+ sites in Texas. The organization is dedicated to delivering high-quality, evidence-based cancer care, utilizing leading-edge technology and research to help patients achieve "More breakthroughs. More victories." The US Oncology Network, supported by McKesson Corporation, aims to advance cancer care through a vibrant and sustainable community patient care delivery system. The Clinical Insurance Reviewer, under general supervision, is responsible for reviewing chemotherapy regimens according to reimbursement guidelines, obtaining necessary pre-certifications and exceptions to ensure timely reimbursement, and researching denied services and alternative payment resources. The role also involves supporting and adhering to the US Oncology Compliance Program, including the Code of Ethics and Business Standards.

Requirements

High school degree or equivalent.
Minimum three (3) years medical insurance verification and authorization and two (2) years clinical review experience required (for Level Sr).
Possesses up to date knowledge of the profession and industry; is regarded as an expert in the technical/functional area; accesses and uses other expert resources when appropriate (Uses Technical and Functional Experience).
Handles day to day work challenges confidently; is willing and able to adjust to multiple demands, shifting priorities, ambiguity and rapid change; shows resilience inn the face of constraints, frustrations, or adversity; demonstrates flexibility (Demonstrates Adaptability).
Makes timely, cost effective and sound decisions; makes decisions under conditions of uncertainty (Uses Sound Judgment).
Sets high standards of performance; pursues aggressive goals and works efficiently to achieve them (Shows Work Commitment).
Emphasizes the need to deliver quality products and/or services; defines standards for quality and evaluated products, processes, and service against those standards; manages quality; improves efficiencies (Commits to Quality).

Nice To Haves

Associates degree in Healthcare, LPN state license and registration preferred.
Minimum three (3) years medical insurance verification and authorization preferred (for Level 1).

Responsibilities

Reviews, processes and audits the medical necessity for each patient chemotherapy treatment and documentation of regimen relative to pathway adherence.
Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with particular insurance plans.
Provides prompt feedback to physicians and management regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.
Updates coding/payer guidelines for clinical staff.
Tracks pathways and performs various other business office functions on an as needed basis.
Obtains insurance authorization and pre-certification specifically for chemotherapy services.
Works as a patient advocate and functions as a liaison between the patient and payer to answer reimbursement questions and avoid insurance delays.
Researches additional or alternative resources for non-covered chemotherapy services to prevent payment denials.
Provides a contact list for patients community resources including special programs, drugs and pharmaceutical supplies and financial resources.
Maintains a good working knowledge of chemotherapy authorization requirements for all payers, State and federal regulatory guidelines for coverage and authorization.
Adheres to confidentiality, state, federal, and HIPPA laws and guidelines with regards to patients records.
Other duties as requested or assigned.