Insurance Authorization Specialist

The US Oncology Network•Denton, TX

21h•Remote

About The Position

The Insurance Authorization Specialist works under general supervision in Texas Oncology’s Medical Authorizations Department, reviewing chemotherapy regimens against reimbursement guidelines and obtaining the necessary pre-certifications and exceptions to prevent treatment reimbursement delays. The role researches denied or non-covered services and alternative resources, supports patients with reimbursement questions, and helps connect them with community, pharmaceutical, and financial resources. The position may be Level 1 or Senior, based on the candidate’s work experience. This is a full-time remote position supporting the clinic at 2600 Scripture Road in Denton, Texas. The typical schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. The role works with clinical staff, physicians, management, patients, and payers, and must maintain knowledge of payer authorization requirements and applicable regulatory and confidentiality guidelines.

Requirements

Level 1: High school degree or equivalent.
Level 1: Minimum three years of medical insurance verification and authorization experience preferred.
Senior level: Minimum three years of medical insurance verification and authorization experience and two years of clinical review experience required.
Demonstrated technical and functional expertise, adaptability, sound judgment, work commitment, and commitment to quality.
Meet the physical demands described for the role, including sitting or standing, talking or hearing, extensive standing and walking, and occasionally lifting and carrying items up to 40 pounds.

Nice To Haves

Associate degree in Healthcare preferred.
LPN state license and registration preferred.
Level 1: Minimum three years of medical insurance verification and authorization experience preferred.

Responsibilities

Review, process, and audit the medical necessity of each patient’s chemotherapy treatment and documentation of the regimen relative to pathway adherence.
Obtain insurance authorizations and pre-certifications for chemotherapy services.
Communicate with nursing and medical staff about insurance-plan restrictions or special requirements.
Provide prompt feedback to physicians and management about pathway documentation issues and payer issues involving non-covered chemotherapy drugs.
Update clinical staff on coding and payer guidelines.
Track pathways and perform other business office functions as needed.
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 information for community resources, 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 HIPAA guidelines.
Support and adhere to the US Oncology Compliance Program, including its Code of Ethics and Business Standards.
Perform other duties as requested or assigned.