Clinical Insurance Reviewer: Fast-Track Authorizations & Denials

The US Oncology Network; Antioch (CA); On-site; USD 34,000 - 45,000; Full time

Job summary

The US Oncology Network is seeking an Authorization Specialist to handle referrals and pre-authorizations for patient care. You will review orders, determine CPT/HCPCS requirements, and communicate with insurers and care sites to obtain approvals.

Responsibilities include auditing, updating WQ notes, and escalating denials for peer-to-peer or appeals as needed. Requires EMR experience and medical billing knowledge.

Qualifications

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

Responsibilities

• Perform timely review of assigned WQs to ascertain next steps; prioritizing requests based on due date, stat, urgent, etc.
• Review patient chart for MD orders to determine services/CPTs/HCPCs and reasons for requests.
• Review insurance guidelines; gather data for phone, on-line and/or fax to insurance; request Pre D if applicable.
• If services do not meet payer guidelines, contact RCAUTHSUP and/or ordering provider for next steps; appeal if denied.
• 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; ensure responses within 48 hrs.
• Assist in managing WQ; ensure meeting goals, update notes, review delayed referrals.
• Maintain 95% audit/productivity score.
• Navigate and troubleshoot authorization issues/denials (non-contracted facility, non-preferred drug).

Education

High school degree or equivalent

Associates degree in Business Admin/related field

Certificate Medical Billing or Insurance

Tools

EPIC EMR

E-scan

Job description

The US Oncology Network is seeking an Authorization Specialist to handle referrals and pre-authorizations for patient care. You will review orders, determine CPT/HCPCS requirements, and communicate with insurers and care sites to obtain approvals.

Responsibilities include auditing, updating WQ notes, and escalating denials for peer-to-peer or appeals as needed. Requires EMR experience and medical billing knowledge.