Insurance Reviewer Clinical

The US Oncology Network•Ocala, FL

3d•Onsite

About The Position

Under general supervision, this role reviews chemotherapy regimens in accordance with reimbursement guidelines. The position is responsible for obtaining necessary pre-certifications and exceptions to ensure timely reimbursement of treatments. It also involves researching denied services and alternative resources to cover treatment costs. The role requires adherence 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 required.
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.
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.
Makes timely, cost effective and sound decisions; makes decisions under conditions of uncertainty.
Sets high standards of performance; pursues aggressive goals and works efficiently to achieve them.
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.

Nice To Haves

Associates degree in Healthcare
LPN state license and registration preferred.

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 patient's records.
Other duties as requested or assigned.