Clinical Insurance Reviewer

US Oncology Inc.; Norfolk (VA); On-site; USD 42,000 - 64,000; Full time

Job summary

US Oncology Inc. is seeking a detail-oriented insurance verification specialist to support oncology treatment reimbursements in Norfolk, VA.

The role involves reviewing chemotherapy regimens for medical necessity and ensuring timely pre-certifications to prevent delays in payment. The position requires experience in insurance verification, authorization, and payer communications, with preference for an LPN or allied health background.

Qualifications

• High school degree or equivalent; associates degree preferred.
• Minimum three (3) years medical insurance verification and authorization experience.

Responsibilities

• Reviews and audits medical necessity for chemotherapy regimens and documents adherence to pathways.
• Communicates with nursing and medical staff regarding restrictions or payer requirements.
• Updates coding/payer guidelines for staff and tracks pathways.
• Obtains insurance authorization and pre-certification for chemotherapy services; acts as liaison between patient and payer.
• Researches additional resources for non-covered chemotherapy services and informs patients about community resources.

Skills

Medical insurance verification

Authorization processing

Staff communication

Education

Associates degree in Healthcare

LPN license (preferred)

Job description

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.

ESSENTIAL DUTIES AND 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.

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 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.