Insurance Prior Authorization Specialist - Remote (Southern Nevada Only)

US Oncology Inc.; Henderson (NV); Remote; USD 52,000 - 76,000; Full time

Job summary

Comprehensive Cancer Centers of Nevada (CCCN) seeks a Remote Insurance Prior Authorization Specialist in Southern Nevada to review chemotherapy regimens for medical necessity and obtain necessary pre-certifications. You will work with nursing and medical staff to ensure pathways align with payer guidelines and minimize reimbursement delays.

Responsibilities include updating payer guidelines, using EMR and payer portals, and researching alternatives to cover non-covered services while maintaining

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.

Responsibilities

• Reviews, processes and audits the medical necessity for each patient’s chemotherapy treatment and documentation of regimen relative to pathway adherence.
• Communicate with nursing and medical staff to inform them of restrictions or special requirements in accordance with insurance plans.
• Updates coding/payer guidelines for clinical staff and tracks pathways.
• Obtains insurance authorization and pre-certification for chemotherapy services; acts as a liaison between patient and payer to avoid delays.
• Uses multiple EMR, payor portals and third-party online portals to submit authorization or verify coverage.
• Researches additional resources for non-covered chemotherapy services to prevent denials and provides community resource contacts.
• Maintains knowledge of chemotherapy authorization requirements for all payers and adheres to HIPAA.

Skills

Insurance verification

Pre-certification

EMR systems

Education

High school degree or equivalent

Associates degree in Healthcare, LPN license preferred

Tools

EMR systems

Payor portals

Third-party portals

Job description

Overview

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 provides the most effective treatments, both existing and emerging, 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 professionals are encouraged to join us.

Career Opportunity

Comprehensive Cancer Centers of Nevada is seeking a Remote Insurance Prior Authorization Specialist in Southern Nevada only.

SCOPE

Under general supervision, reviews chemotherapy regimens in accordance with 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’s chemotherapy treatment and documentation of regimen relative to pathway adherence.
• Communicate 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 perform 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.
• Ability to use multiple EMR, payor portals and third-party online web portals to electronically submit authorization or verify that the ordered service is a covered benefit of the health plan.
• Research additional or alternative resources for non-covered chemotherapy services to prevent payment denials. Provides a contact list for patient’s 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 patients’ records.
• Other duties as requested or assigned.

Qualifications

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.

Successful candidates will thrive in a fast-paced, rapidly changing environment and have a passion for caring for their patients.

The US Oncology Network is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. This employer participates in E-Verify.