Pharmacy Clerk

Chemotherapy Authorization Reviewer

HOURLY RATE (DEPENDING ON SKILLS/EXPERIENCE: $25.75 - $31.64

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

• 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.
• Communicates with Patients, Insurances and Pharmacies for any prior authorization needs.
• 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.
• 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

• High School degree or equivalent required

EXPERIENCE REQUIREMENTS :

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

WORK ENVIRONMENT : The work of this position is performed in an environmentally controlled medical practice environment. The position requires the ability to work under pressure and with a diverse population, including staff, physicians, clients, patients, insurance companies and other members of the public on a regular basis. The position may cause frequent exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinical environment.