Insurance Prior Authorization Specialist - Remote (Southern Nevada Only)

Comprehensive Cancer Centers of Nevada; Henderson (NV); Remote; USD 48,000 - 64,000; Full time

Job summary

Comprehensive Cancer Centers of Nevada seeks a Remote Insurance Reviewer - Clinical (Treatment Prior Authorization Specialist) to support Southern Nevada. You will review orders for prior authorization, communicate with clinicians, and ensure timely authorizations to prevent care delays.

In this role, you will navigate multiple payer portals, stay abreast of authorization requirements, and advise on denials or alternative testing when needed.

Qualifications

• High school diploma or equivalent.
• Associates degree in Healthcare; LPN license preferred.
• Minimum three years medical insurance verification and authorization required.
• Experience using electronic medical record portals.

Responsibilities

• Reviews and audits medical necessity for patient orders and prior authorizations according to plans and NCCN guidance.
• Communicates with nursing and medical staff regarding restrictions, requirements, and denials; provides next steps to providers.
• Updates coding/payor guidelines for clinical staff and tracks payer trends.
• Submits authorizations electronically using EMR payor portals and third-party portals; ensures services are covered benefits.
• Acts as patient advocate to answer reimbursement questions and avoid delays.

Skills

Medical insurance verification

Authorization

Education

High school diploma or equivalent

Associates degree in Healthcare

LPN license (preferred)

Tools

EMR portals

Job description

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Insurance Prior Authorization Specialist - Remote (Southern Nevada Only)

• Henderson, Nevada
• Revenue Cycle
• Comprehensive Cancer Centers of Nevada
• 43554

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 Reviewer - Clinical (Treatment Prior Authorization Specialist) in Southern Nevada only.

Scope

Under general supervision, reviews all orders for prior authorization. Orders can include but are not limited to diagnostic radiology, outside consultations and procedures, outside specialty laboratory, in-house treatment, radiation and external procedures to comply with reimbursement guidelines and authorization requirements. Obtains necessary authorizations, pre-certifications or predeterminations to prevent delays in patient care. Relays denied services and provides next level steps for denial or alternative recommendation to the Provider for ordered testing. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Reviews, processes and audits the medical necessity for each patient’s external diagnostic order in accordance with the benefits of the plan, prior authorization, or predetermination processes and NCCN guidance, when appropriate.
• Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with insurance plans. Provides prompt feedback to physicians and management regarding any non-covered or repeated denials, and payer issues with non-covered services requested.
• Updates or contributes coding/payer guidelines for clinical staff. Records any trends from the payors and performs various other business office functions on an as needed basis
• Electronically submits authorization or verifies that the ordered service is a covered benefit of the health plan. Uses multiple electronic medical records (EMR) payor portals and third-party online web portals to submit.
• Ability to work in a paperless environment using digital documents.
• Works as a patient advocate and functions as a liaison between the patient and payer to answer reimbursement or authorization questions and avoid insurance delays.
• Maintains a good working knowledge of 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

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.
• Experience using electronic medical record portals.

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.

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

In addition to a great career opportunity, we offer excellent benefits, a team environment, professional development, and the chance to be part of a nationwide network dedicated to fighting the war against cancer.

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.