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Coord Insurance Spec

4 months ago

South Bend, United States Beacon Health System Full time

Reports to the Director/Manager of Oncology Service line. Coordinates the daily operational activities of Oncology Insurance Specialist associates (i.e., assigns work, facilitates department meetings and is responsible for associate scheduling, annual reviews and disciplinary actions, etc.).

**MISSION, VALUES and SERVICE GOALS**
- **MISSION**:We deliver outstanding care, inspire health, and connect with heart.
- **VALUES**: Trust. Respect. Integrity. Compassion.
- **SERVICE GOALS**: Personally connect. Keep everyone informed. Be on their team.

**Coordination of Denials and Authorization/Pre-Certification functions by**:

- Coordinates the team to ensure that pre-certification authorizations are completed accurately for all outpatient and inpatient chemotherapy/infusion therapy, outpatient diagnostic procedures, outpatient and inpatient planned surgeries, specialty lab testing and therapeutic radiation oncology treatments s ordered by providers.
- Responsible for follow-up and resolution on insurance/authorization related denial issues for oncology service line.
- Responsible for reporting to management on trends/denials/concerns and working collaboratively to resolve.
- Responsible for ongoing education of coding, billing, and payer updates across Insurance Specialist team.
- Supervises team for appropriate coverage of services across all areas to maintain quality, efficient work without interruption to patient care.
- Distributing work assignments for team members to ensure that all verification of benefits, medical necessity checks, authorizations/pre-authorizations have been finalized.
- Auditing authorizations for accuracy.
- Investigating daily 835 denials for continuous process improvement.
- Ensuring that pre-certification authorizations are complete for all scheduled outpatient diagnostic, outpatient and planned inpatient surgeries, and specialty lab testing.
- Ensuring that pre-certification authorizations are completed on all planned chemo admissions.
- Following up with oncology schedulers and physicians to address errors in pre-certifications that have been submitted and requesting rescheduling of the procedure.
- Notifying patients of non-coverage or limited coverage.
- Working closely with social work and financial counselors on self-pay or under insured patients.
- Explaining about the possible need to pre-certify with the patient's insurance carrier in order to ensure maximum coverage to the limits of the insured's insurance policy.
- Verifying and documenting insurance coverage via online eligibility systems, internet resources or via telephone.
- Validating medical necessity via the MCA Compliance Checker where applicable.
- Ability to efficiently access insurance payer portals for best practice of obtaining authorizations.
- Investigating and responding to insurance-related concerns from patients and/or oncology office staff.
- Actively participates and helps to coordinate denial meetings and helps to follow up on ongoing denials until they are resolved.
- Delivers accurate documentation to Insurance Companies.
- Works closely with BMG Oncology physicians and clinical staff to obtain prior authorizations for treatments, procedures, medications, and surgeries.
- Advises office staff when requested procedure(s) have been denied or an insurance company is requesting a peer to peer. Provides all necessary information and documentation in order this to be addressed.
- Communicates effectively with staff regarding authorization-specific details (ie; doses, units, visits).

**Coordinates both the Denials and Authorization/Pre-Certification/documentation (PA) processes for patients by**:

- Running insurance eligibility, make needed phone calls to insurance companies, fax authorization requests.
- Works closely with Patient Accounts to properly follow up on insurance company denials and appeals.
- Obtaining pre-certification information from the insurance company's pre-certification unit (i.e., whether pre-certification is required, if the ordering physician has completed it, etc.).
- Securing authorization on all patients for ancillary, surgical, and out-patient testing/procedures/admissions.
- When the authorization is not completed prior to the ordered procedure, assists with ensuring that the procedure is cancelled or rescheduled.
- Runs & ensures medical necessity is complete with proper CPT and ICD-10 codes as physician order specifies.
- Identifying out of network insurance plans and follow the out of network policy.
- Keeping accurate worklists and documentation.

**Coordinates other patient services and performs clerical duties by**:

- Reviews all insurance coding changes regarding updates to HCPCS and CPT codes.
- Verifies treatment meets medical necessity per diagnosis given by providers.
- Calculating co-payments and coinsurance for services rendered (either verbally or in writing) per the insurance companies' request.
- Processing denials and authorizations in an efficient manner.