Insurance Prior Authorization Specialist - Remote (Southern Nevada Only)

About the role

Comprehensive Cancer Centers of Nevada (CCCN) is seeking a Remote Insurance Reviewer – Clinical (Treatment Prior Authorization Specialist) in Southern Nevada only. Under general supervision, the role reviews chemotherapy regimens in accordance with reimbursement guidelines, obtains necessary pre-certifications and exceptions, and researches denied services and alternative resources to ensure timely reimbursement of treatments. The position supports and adheres to the US Oncology Compliance Program, including 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.
• Communicates with nursing and medical staff to inform them of restrictions or special requirements per 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 and tracks pathways, performing various business office functions as needed.
• Obtains insurance authorization and pre-certification specifically for chemotherapy services.
• Acts as a patient advocate and 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, pharmaceutical supplies, and financial resources.
• Maintains a strong working knowledge of chemotherapy authorization requirements for all payers, as well as state and federal regulatory guidelines for coverage and authorization.
• Adheres to confidentiality, state, federal, and HIPAA laws and guidelines regarding patients’ records.
• Performs other duties as requested or assigned.

Qualifications

• High school degree or equivalent.
• Associates degree in Healthcare, LPN state license and registration preferred.
• Minimum three (3) years of medical insurance verification and authorization experience required.

Competencies

• Uses Technical and Functional Experience: Possesses up-to-date knowledge of the profession and industry; 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; 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 evaluates 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.

• 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 involves in-person interaction with co-workers, 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 patients.