Prior Authorization Reviewer

Overview

SCOPE: Under general supervision, reviews chemotherapy regimens in accordance to reimbursement guidelines. Obtains necessary pre-certifications and exceptions to ensure no delay in reimbursement of treatments. Researches denied services and alternative resources to pay for treatment. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

The US Oncology Network is a thriving organization that fosters forward-thinking, advancement opportunities, and an inspired work environment. We continuously look for top talent who will continue to propel our organization in the right direction and celebrate new successes! Come join our team in the fight against cancer!

About US Oncology
The US Oncology Network is one of the nation’s largest networks of community-based oncology physicians dedicated to advancing cancer care in America. The US Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care. For more information, visit www.usoncology.com. We extend an extremely competitive offering of benefits to employees, including Medical Health Care, Dental Care, Vision Plan, 401-K with a matching component, Life Insurance, Short-term and Long-term disability, and Wellness & Perks Programs.

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.

Qualifications

MINIMUM QUALIFICATIONS:

High school degree or equivalent. Associates degree in Healthcare, LPN state license and registration 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.

 -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.

PHYSICAL DEMANDS:

 The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lift and carry items weighing up to 40 lbs. Requires corrected vision and hearing to normal range.

WORK ENVIRONMENT:

The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations and other conditions common to an oncology/hematology clinic environment. Work may involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites.