Prior Authorization Specialist

$41,600 - $52,000/Yr

US Oncology Network - Norfolk, VA

Full-time - Mid Level

Norfolk, VA

Ambulatory Health Care Services

About the position

The Prior Authorization Specialist plays a crucial role in ensuring that chemotherapy treatments are authorized and reimbursed according to insurance guidelines. This position involves reviewing treatment regimens, obtaining necessary pre-certifications, and acting as a liaison between patients and payers to facilitate timely reimbursement. The role supports compliance with The US Oncology Network's standards and aims to enhance patient care in the oncology field.

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 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.
• Research additional or alternative resources for non-covered chemotherapy services to prevent payment denials.
• Provides a contact list for patient's 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.

Requirements

• High school diploma or GED required.
• Associate's degree in Healthcare preferred.
• Minimum of 3 years of experience in medical insurance verification and authorization required.

Benefits

• Paid holidays
• Disability insurance
• Health insurance
• Dental insurance
• 401(k)
• Paid time off
• Vision insurance
• 401(k) matching
• Life insurance