Insurance Reviewer - Clinical

The essential duties and responsibilities of this position are: 

• Obtains prior authorization for scans, labs, subsequent chemotherapy visits or any other service as required. 

• Maintains a professional working relationship with co-workers, insurance companies and referring doctor offices.

• Assists in receiving and reviewing orders from CCK providers to analyze if necessary to, and then when necessary, obtain prior-authorization.

• Receives and reviews clinical documents within the electronic medical record (“EMR”) in order to meet requirements for obtaining the authorization.

• Services responsible for obtaining prior authorizations for may include radiology, laboratory, chemotherapy and injections.

• Contacts referring physicians and facilities to obtain referrals for all services scheduled at CCK.

• Provides clinical information to insurance companies and case managers as needed. 

• Coordinates peer to peer calls between physicians and insurance companies.

• Assists in maintaining up to date information on insurance requirements for all authorization needs per payer.

• Uploads and attaches authorizations and referrals to the practice management system (“PMS”) and EMR as needed.

• Contacts insurance companies through effectively navigating company websites, managed care portals and through methods such as phone and fax in order to complete prior authorization information requests for ordered services.

• Timely and accurate entry of information in the PMS and EMR.

• Follows the status of authorizations and referrals to ensure timely receipt.

• Ability to multi-task and communicate through various mediums. 

• Maintains a good working knowledge of chemotherapy authorization requirements for all payers, State and federal regulatory guidelines for coverage and authorization. 

• Remains current on all compliance requirements and in part, demonstrates knowledge of Adheres to confidentiality, state, federal, and HIPPA (Health Insurance Portability and Accountability Act) laws and guidelines with regards to patient’s records and information.

• Attends required, applicable meetings.

• Remains current on all compliance requirements.

• Ensures all applicable policies and procedures of the company and Network are followed.

• Other duties as requested or assigned including coverage within the department.

• Performs other tasks as reasonably requested by a provider or member of the Management Team, as applicable to the role.

Supervisory Responsibilities:

• None.

The ideal candidate for the position will have the following qualifications: 

Minimum Qualifications:

• High school degree or equivalent. 

• Associates degree in Healthcare or Business-related preferred. 

• Minimum three (3) years medical insurance verification and authorization required.  
  

Competencies:

• Uses Technical and Functional Experience: 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.

• Demonstrates Adaptability: 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.

• Uses Sound Judgment: Makes timely, cost effective and sound decisions; makes decisions under conditions of uncertainty.

• Shows Work Commitment: Sets high standards of performance; pursues aggressive goals and works efficiently to achieve them.

• Demonstrates Team-Oriented Characteristics: Fosters a positive and productive team environment by working effectively with others and offering help when able.

• Commits to Quality: 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.