Insurance Reviewer-Clinical

Overview

HOURY RATE (DEPENDING ON SKILLS/EXPERIENCE): $25.75 - $33.60

SCOPE: Responsible for working in assigned referral WQs to obtain required referrals/authorizations for requested patient care.  Review orders and interpret what services/CPT/HCPCs are required. Perform required follow up until receipt of final decision; if not favorable reach out to provider to request next steps.  Provide communication between Authorization Department and sites via email, phone and/or in-basket. Proficient in navigation and interpretation of payer requirements, contracted facilities and payer preferred drugs if applicable.  Ability to easily understand and interpret orders and therapy plans to insure accuracy and efficiency of authorization submissions.  Based on payer requirements enter request attaching required medical records.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

• Perform timely review of assigned WQs to ascertain next steps; prioritizing requests based on due date, stat, urgent, etc.  Monitor and process external order WQs
• Review patient chart for MD orders to determine services/CPTs/HCPCs and reasons for requests.
• Review insurance guidelines.  If services requested meet medical necessity, gather data to be prepared for phone call, on-line and/or fax to insurance. If no auth required request a Pre D and return authorization approved.
• If services do not meet payer guidelines, reach out to RCAUTHSUP and/or ordering provider for next steps.  If request is denied by insurance, request for peer to peer and/or submit written appeal.
• Enter authorized services into system and all notes pertaining to phone calls
• Provide communication for sites/providers via email, phone and/or in-basket.
• Maintain in box and fax folder; import medical guidelines via E-scan into EPIC.
• Assist in managing in-basket messages; ensuring all have been appropriately responded to within 48 hrs.
• Assist in managing WQ ; ensuring WQ is meeting goal, all WQ notes are updated and any delayed referrals reviewed and identifying trends
• Maintain a 95% or greater audit and productivity score. 
• Be able to navigate and trouble shoot authorizations related issues/denials : IE non-contracted facility chosen, non-preferred drug etc.

Qualifications

MINIMUM QUALIFICATIONS:

• High school degree or equivalent.
• Associates degree in Business Admin/related field preferred. 
• Certificate Medical Billing or Insurance preferred.

EXPERIENCE REQUIREMENTS: 

• 1 Year Healthcare Insurance in Medical/Hospital environment required.
• 1 Year EMR required. 
• 1 Year RCAurh required.

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 accommodations 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 lifts and carries items weighing up to 20lbs. 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 will involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites.