Clinical Reviewer Jobs

About The Position

Requirements

• High school degree or equivalent.
• For the Senior level, at least three years of medical insurance verification and authorization experience and two years of clinical review experience are required.
• Ability to perform the described essential job functions, with reasonable accommodations where applicable.

Nice To Haves

• Associate degree in Healthcare.
• LPN state license and registration.
• At least three years of medical insurance verification and authorization experience for Level 1.

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 and 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 clinical staff on coding and payer guidelines.
• 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 regulatory guidelines for coverage and authorization.
• Protect patient records and follow confidentiality requirements and applicable state and federal laws and guidelines, including HIPAA.
• Support and adhere to the US Oncology Compliance Program, including the Code of Ethics and Business Standards.
• Perform other duties as requested or assigned.