Pre-Access Infusion Benefits and Authorization Specialist Oncology

AdventHealth; Altamonte Springs (FL); Remote; USD 40,000 - 60,000; Full time

Job summary

AdventHealth is seeking a Pre-Access Infusion Benefits and Authorization Specialist to join their team. In this role, you will ensure that insurance authorization for chemotherapy treatments is secured, confirming medical necessity and maintaining communication with clinical partners. The position requires strong background knowledge in oncology, patient access, and insurance verification. The ideal candidate will thrive in a fast-paced environment and provide excellent customer service while adhering to compliance standards.

Benefits

Benefits from Day One

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

Qualifications

• 3+ years experience in oncology operations or patient access.
• Familiarity with medical terminology required.
• Understanding of HIPAA privacy rules.

Responsibilities

• Verify authorizations and insurance benefits for treatments.
• Maintain relationships with clinical partners.
• Communicate coverage and eligibility information to patients.

Skills

Oncology related business operations

Insurance verification

Patient access experience

Customer service experience

Intermediate medical terminology

Education

High School Grad or Equivalent

Job description

AdventHealth Corporate

All the benefits and perks you need for you and your family:

· Benefits from Day One

· Career Development

· Whole Person Wellbeing Resources

· Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part

of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Shift : Full-time; Monday-Friday, 8a - 4:30p CST or 8:30a-5p CST

Job Location : Remote

The role you will contribute:

The Pre-Access Infusion Benefits and Authorization Specialist, under general supervision, maintains performance standards appropriate to area by obtaining account benefits and/or verifying authorizations are in place for all chemotherapy regimens and treatments, and meeting standards established by leadership for all patient services. Meets or exceeds department audit accuracy and productivity standard goal. Uses utmost caution that obtained benefits, authorizations, and/or pre-certifications are accurate according to the actual test, and procedure or registration being performed. Adheres to AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you will bring to the team:

• Responsible for review of chemotherapy regimen/treatment orders and determines insurance benefits and authorization requirements.Reviews clinical data such as patient pathology reports, scans, laboratory results, prior treatments, matching against insurance payor and/or National Comprehensive Cancer Network (NCCN) guidelines. Ensures specified medical terms, diagnosis, medication codes and supporting clinical documentations are met. Utilization review to facilitate the sending of clinical information in support of the authorization to payor or third-party administrators, as assigned. • Reviews medical records in detail to confirm the treatment is supported by approved medical studies by reputable oncology/hematology studies. Stays current on payer preference for biosimilar drugs available. Ensures patient orders are changed accordingly if biosimilar drug is preferred. Ensures that each treatment is coded, reviewed, and financially cleared based on the patient insurance requirements. • Verifies medical necessity in accordance with Centers for Medicare & Medicaid Services (CMS) standards by reviewing guidelines and communicates relevant coverage/eligibility information to the patient. Alerts physician offices to issues with verifying insurance. Responsible for communicating to service line partners of situations where medical necessity is not met to include review of journal articles, compendia and/or peer review to justify medical necessity approval • Reviews clinical records when following up on authorization request directly with a payor. Escalates peer to peer (insurance company physician requests to speak to ordering physician) requests to physician offices and assists in scheduling peer to peer requests with the office and the payer to ensure an authorization decision is made prior to date of service. • Obtains initial and subsequent pre-authorization for chemotherapy treatments, as well as research protocols, on all new and existing patients and notes approvals in the electronic medical record. Uploads treatment supporting documentation packet to the electronic medical record for Revenue Cycle billing and coding teams. • Contacts insurance companies by phone, fax, online portal, and other resources to obtain and verify insurance eligibility and benefits and determine extent of coverage within established timeframe before scheduled appointments and during or after care for unscheduled patients • Obtains pre-authorizations from third-party payers in accordance with payer requirements and within established timeframe before scheduled appointments and during or after care for unscheduled patients. Accurately enters required authorization information in AdventHealth systems to include length of authorization, total number of visits, and/or units of medication. Convert orders and dosage to ensure the proper authorization is requested and approved, based on the units the payer has given. • Maintains a close working relationship with clinical partners and physician offices to ensure continual open communication between clinical, ancillary, and Patient Access & Patient Financial Services departments by monitoring team e-mail boxes and phone calls to follow up on issues timely. Responsible for communicating to service line partners of situations where rescheduling is necessary, due to lack of authorization or limited benefits.

The expertise and experiences you’ll need to succeed:

· High School Grad or Equiv and 3+ years experience

· 1+ year experience in Oncology related business operations within specialty pharmacy or insurance verification, payor reimbursement guidelines, and/or authorization submission. Familiarity with medical terminology and concepts. Working knowledge with third party insurance administrators authorization and clinical care processes.

· 1+ year of direct Patient Access experience

· 1+ year of customer service experience

· Understanding of HIPAA privacy rules and ability to use discretion when discussing patient related information that is confidential in nature as needed to perform duties

· Intermediate medical terminology

Preferred Qualifications:

· Pharmacy Technician Preferred

· Certified Healthcare Access Associate (CHAA) Preferred

· Certified Revenue Cycle Representative (CRCR) Preferred

· 2+ years of direct Patient Access experience Preferred

· Medical Assistant Preferred

· Associate Preferred