Insurance Clinical Reviewer

Overview The US Oncology Network is looking for a Clinical Insurance Reviewer to join our team at Texas Oncology. This full-time remote position will support the Central Imagine Scheduling Department at our 500 South Henderson Suite 400 clinic in Fort Worth, Texas. Typical work week is Monday through Friday, 8:30a-5:00p. This position will be either a level 1 or Sr based on candidate work experience. As part of the US Oncology Network, Texas Oncology delivers high-quality, evidence-based care to patients close to home. Texas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas. Our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. Our mission is still the same today—at Texas Oncology, we use leading-edge technology and research to deliver high-quality, evidence-based cancer care to help our patients achieve breakthroughs and victories in their fight against cancer. Today, Texas Oncology treats half of all Texans diagnosed with cancer on an annual basis. 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. What does the Clinical Insurance Reviewer do? 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 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 HIPAA laws and guidelines with regards to patient records. Other duties as requested or assigned. Qualifications The ideal candidate for the Insurance Reviewer position will have the following background and experience: Level 1 High school degree or equivalent. Associates degree in Healthcare, LPN state license and registration preferred. Minimum three (3) years medical insurance verification and authorization preferred. Level Sr (in addition to level 1 requirements) Minimum three (3) years medical insurance verification and authorization and two (2) years clinical review experience 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 in 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 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. #J-18808-Ljbffr US Oncology Inc.