Prior Authorization Representative

Employment Type: Full Time

In-Office Position

Benefits: M/D/V, Life Ins., 401(k), PTO, Paid Holidays 

Henderson, Nevada

JOB SCOPE: 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. Research denied services and alternative resources to pay for treatment. Supports and adheres to The US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

The US Oncology Network is a thriving organization that fosters forward-thinking, advancement opportunities, and an inspired work environment. We continuously look for top talent who will continue to propel our organization in the right direction and celebrate new successes! Come join our team in the fight against cancer!
About US Oncology
The US Oncology Network is one of the nation’s largest networks of community-based oncology physicians dedicated to advancing cancer care in America. The US Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care. For more information, visit www.usoncology.com. We extend an extremely competitive offering of benefits to employees, including Medical Health Care, Dental Care, Vision Plan, 401-K with a matching component, Life Insurance, Short-term and Long-term disability, and Wellness & Perks Programs.

ESSENTIAL DUTIES AND 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.
• Other duties as requested or assigned.

Minimum Qualifications:

• High school degree or equivalent. Associates degree in Healthcare.
• Minimum three (3) years medical insurance verification and authorization required.