Performs prior authorization/certification of scheduled services with payers & assist with appeal process when needed. Provides clinical review and document submission of pre-certification requests for oncology treatments plans and services. Interfaces with payers on plan medical coverage policies.
ACCOUNTABILITIES All duties listed below are essential unless noted otherwise 1. Performs clinical review and document submission to obtain pre-certification/authorization requests for chemotherapy and non-chemotherapy plans, radiation therapy and advance imaging and blood management plans to support patient treatment and follow-up. 2. Completes consistent review of individual payer policies to identify changes affecting authorizations. Maintains current knowledge on medical criteria relating to prior authorization requirements by third party payers and medical necessity requirements. 3. Reviews and assists with denial management reports as instructed. Identifies and reports any payer trends, denial patterns and delays to management. 4. Communicates with cancer center staff regarding authorization status and decisions as appropriate. 5. Participate in process development and improvement as it relates to authorizations, communication, education, etc. 6. General understanding of coding for hospital and imaging services recommended including review of hospital records. 7. Thoroughly documents actions taken in appropriate information system(s). 8. Additional responsibilities/duties will be assigned based on teamwork load and competency.
**This position is Remote, ideally within 120 miles from Toledo, OH. Interviews will be conducted onsite.
Pay Range: $16.25 - $46.35 Education: Nursing degree Skills: Familiarity with ICD10 and CPT codes applicable to services rendered Have demonstrated ability to communicate with medical and administrative staff and patients, understanding levels of care. Have strong organizations skills and the ability to multi-task. Be able to understand directions and be able to communicate and respond to inquiries; requires effective interpersonal and telephone/electronic messaging etiquette skills. Have intermediate computer knowledge, skills and proficiency including general office applications. Demonstrate the ability to accurately and independently solve problems. Have the ability to manage large volumes of work, ability to quickly learn and retain information regarding issues that present themselves. Years of Experience: 2 years of clinical. Experience with electronic record interfaces License: RN Certification: Prior oncology pre-certification/authorization
PREFERRED QUALIFICATIONS Education: Bachelor's degree Skills: Specific knowledge of medical payers Years of Experience: Oncology experience; EPIC electronic health record experience
WORKING CONDITIONS Personal Protective Equipment: Exposure to expected hospital conditions. Physical Demands: Frequent sitting and computer use.
The above list of accountabilities is intended to describe the general nature and level of work performed by the positions; it should not be considered exhaustive.
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or other status protected by applicable law.
Equal Opportunity Employer/Drug-Free Workplace
Requisition ID: 87003
