Prior Authorization Specialist/Clinical Insurance Reviewer - Remote ( Southern Nevada only)
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- Henderson, Nevada
- Revenue Cycle
- Comprehensive Cancer Centers of Nevada
- 39944
Overview
Job Description At Comprehensive Cancer Centers of Nevada (CCCN) a distinguished team of doctors, researchers, nurses and healthcare professionals have provided patients with groundbreaking treatments on the healing edge of medicine for over 50 years. Our team is dedicated to providing the most effective treatments, both existing and emerging, in order to diagnose and successfully treat cancer and blood disorders. We support this goal with state-of-the-art facilities across Southern Nevada, all of which integrate the latest diagnostic, therapeutic and research capabilities. CCCN is dedicated to patient-centered care, advancing innovation, discovery, and improving outcomes. Motivated, caring professional are encouraged to join us. Career Opportunity Comprehensive Cancer Centers of Nevada is seeking a Clinical Insurance Reviewer to work remotely in the Southern Nevada area only. The Clinical Reviewer reviews diagnostic imaging and pulmonary testing orders in accordance to reimbursement guidelines and obtains necessary pre-certifications and exceptions to ensure no delay in reimbursement of treatments. 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.
Responsibilities
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Reviews, processes and audits the medical necessity for each patient radiation oncology treatment, imaging and testing requests
- 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 documentation issues and payer issues with non-covered or denied services
- Updates coding/payer guidelines for clinical staff
- Obtains insurance authorization and pre-certification for imaging, pulmonology and surgical 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 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 diploma or equivalent required
- Associates degree in Healthcare, LPN state license and registration preferred
- Minimum three (3) years medical insurance verification and authorization 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 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 will involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites. Successful candidates will thrive in a fast-paced, rapidly changing environment and have a passion for caring for their