[Hiring] Clinical Insurance Reviewer @The US Oncology Network

Role Description

The US Oncology Network is looking for a Clinical Insurance Reviewer to join our team at Texas Oncology. This full-time remote position will support the Oncology Department at our 1350 First Colony Blvd clinic in Sugarland, Texas. Typical work week is Monday through Friday, 8:30a - 5:00p. This position will be either a level 1 or Sr based on candidate work experience.

As a part of The US Oncology Network, Texas Oncology delivers high-quality, evidence-based care to patients close to home. Texas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas. Our mission is to deliver high-quality, evidence-based cancer care to help our patients achieve “More breakthroughs. More victories.”® in their fight against cancer.

What does the Clinical Insurance Reviewer do? (including but not limited to)

• Under general supervision, reviews chemotherapy regimens in accordance to reimbursement guidelines.
• Obtains necessary pre-certifications and exceptions to ensure no delay in reimbursement of treatments.
• Researches denied services and alternative resources to pay for treatment.
• 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 imaging authorizations and documentation of services needed 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.
• Performs various other business office functions on an as needed basis.
• Obtains insurance authorization and pre-certification specifically for patient imaging.
• Works as a patient advocate and functions as a liaison between the patient and payer to answer reimbursement questions and avoid insurance delays.
• Maintains a good working knowledge of insurance authorization requirements for all payers, state and federal regulatory guidelines for coverage and authorization.
• Adheres to confidentiality, state, federal, and HIPAA laws and guidelines with regards to patient's records.
• Requires attention to detail, organization, high level discernment when reviewing insurance for processing/authorizations.
• Other duties as requested or assigned.

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.

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.
• Demonstrates Adaptability: Handles day to day work challenges confidently; adjusts to multiple demands, shifting priorities, ambiguity and rapid change.
• 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.

Physical Demands

• 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

• Exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations and other conditions common to an oncology/hematology clinic environment.
• In-person interaction with co-workers and management and/or clients.
• Minimal travel by automobile to office sites may be required.