Prior Authorization Reviewer - Remote

The US Oncology Network•Norfolk, NY

11h•Remote

About The Position

Under general supervision, the Prior Authorization Reviewer reviews chemotherapy regimens in accordance with reimbursement guidelines and obtains required pre-certifications and exceptions to prevent delays in treatment reimbursement. The role researches denied services and alternative resources for payment and supports the US Oncology Compliance Program, including its Code of Ethics and Business Standards. The position works with nursing and medical staff, physicians, patients, and payers to manage chemotherapy authorizations, communicate coverage requirements, resolve reimbursement questions, and identify resources for non-covered services. It also maintains knowledge of payer authorization requirements and state and federal coverage regulations, and handles patient records in accordance with confidentiality and applicable laws. Other duties may be assigned. The role is described as remote in the job title; however, the posting also states that the employee is required to be present at the employee site during regularly scheduled business hours. The work environment may include conditions common to an oncology/hematology clinic and may involve in-person interaction and minimal automobile travel to office sites.

Requirements

High school degree or equivalent.
At least three years of medical insurance verification and authorization experience.
Maintain knowledge of chemotherapy authorization requirements, payer rules, and state and federal coverage and authorization guidelines.
Comply with confidentiality requirements and applicable laws and guidelines for patient records.
Demonstrate technical and functional expertise, adaptability, sound judgment, work commitment, and commitment to quality.

Nice To Haves

Associate degree in Healthcare preferred.
LPN state license and registration preferred.

Responsibilities

Review, process, and audit medical necessity for each patient’s chemotherapy treatment and documentation of the regimen relative to pathway adherence.
Communicate insurance-plan restrictions or special requirements to nursing and medical staff; provide prompt feedback to physicians and management about 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 for chemotherapy services.
Act as a patient advocate and liaison between patients and payers to answer reimbursement questions and 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 regulatory guidelines for coverage and authorization.
Protect patient-record confidentiality and follow applicable state and federal laws and guidelines.
Support and adhere to the US Oncology Compliance Program, including the Code of Ethics and Business Standards.
Perform other duties as requested or assigned.