[Hiring] Outside Scheduler/Insurance Reviewer Sr @The US Oncology Network

Role Description

Texas Oncology is looking for an Outside Scheduler/Insurance Reviewer Sr to join our team! This is a REMOTE position that will support the West Region locations (Odessa, Midland, Wichita Falls, Amarillo, Abilene, and El Paso). Hours are M-F, 8A-5P.

What does the Outside Scheduler/Insurance Reviewer Sr do? (including but not limited to)

• Under minimal supervision, dedicated to outside scheduling of physician referrals and/or outside testing as directed by the physician.
• Reviews chemotherapy regimens in accordance with 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.
• Communicates to the patient the type of test, any necessary prep, and the date/time/location of the appointment.
• May help orient, train, and assign the work of lower-level employees.
• Serves as a liaison between patients, medical staff, and referring offices.
• Operates within standard procedures and pre-established guidelines to complete tasks.
• 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 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, 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 HIPAA laws and guidelines with regards to patient records.
• 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 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; is a quick learner in the technical/functional area; accesses and uses other expert resources when appropriate.
• Demonstrates Adaptability: Handles day-to-day work challenges confidently; is 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

• Work may require sitting for long periods of time; also stooping, bending, and stretching for files and supplies.
• Occasionally lifting files or paper weighing up to 30 pounds.
• Requires manual dexterity sufficient to operate a keyboard, calculator, telephone, copier, and other office equipment.
• Vision must be correctable to 20/20 and hearing must be in the normal range for telephone contacts.
• It is necessary to view and type on computer screens for prolonged periods of time.

Work Environment

• Work is performed in an office environment.
• Involves contact with patients and the public.