Insurance Authorization Specialist

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.

Qualifications

• Level 1: High school degree or equivalent. Associates degree in Healthcare, LPN state license and registration preferred. Minimum three (3) years medical insurance verification and authorization preferred.
• Level Sr: Minimum three (3) years medical insurance verification and authorization and two (2) years clinical review experience required.