Description:

Scope

-Under general supervision, reviews IV Therapy 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

Essential Duties and Responsibilities

• Reviews, processes and audits the medical necessity for each patient medical 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 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
• Researches additional or alternative resources for non-covered services to prevent payment denials
• 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 patients records
• Other duties as requested or assigned.

*Normal day: each Clinical Insurance Reviewer works out of a que - each support specific providers at at various clinics across the East Coast (they will be tied to the same providers - anywhere from 4-6). They sort authorizations needed by due date or start date that the provider puts in and works backwards. They are using the insurance carrier portals, navigating pathways, calling into insurance companies and faxing to obtain authorizations. The goal is to work 3 days in advance for authorizations.

Additional Skills & Qualifications:

1+ years of prior authorization experience

IV / injectable drug experience highly preferred

Insurance payer knowledge

Payer website knowledge

CPT coding experience/knowledge

HCPCS coding knowledge is helpful

ICD-10 coding knowledge

About Aston Carter:

At Aston Carter, we’re dedicated to expanding career opportunities for the skilled professionals who power our business. Our success is driven by the talented, motivated people who join our team across a range of positions – from recruiting, sales and delivery to corporate roles. As part of our team, employees have the opportunity for long-term career success, where hard work is rewarded and the potential for growth is limitless.

Established in 1997, Aston Carter is a leading staffing and consulting firm, providing high-caliber talent and premium services to more than 7,000 companies across North America. Spanning four continents and more than 200 offices, we extend our clients’ capabilities by seeking solvers and delivering solutions to address today’s workforce challenges. For organizations looking for innovative solutions shaped by critical-thinking professionals, visit AstonCarter.com. Aston Carter is a company within Allegis Group, a global leader in talent solutions.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please call 888-237-6835 or email astoncarteraccommodation@astoncarter.com for other accommodation options. However, if you have questions about this position, please contact the Recruiter located at the bottom of the job posting. The Recruiter is the sole point of contact for questions about this position.