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Infusion Benefits/Authorization Specialist

1 month ago

Calhoun, United States AdventHealth Full time

All the benefits and perks you need for you and your family: · Benefits from Day One · Paid Days Off from Day One · Student Loan Repayment Program · Career Development · Whole Person Wellbeing Resources Our promise to you: Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. Schedule: Part Time Shift: Days 16-24 hours /week Location: . 1035 REDBUD RD., SUITE 101 The role you'll contribute: The Pre-Access Infusion Benefits and Authorization Specialist, under general supervision, maintains performance standards appropriate to area by obtaining account benefits and/or verifying authorizations are in place for all chemotherapy regimens and treatments, and meeting standards established by leadership for all patient services. Meets or exceeds department audit accuracy and productivity standard goal. Uses utmost caution that obtained benefits, authorizations, and/or pre-certifications are accurate according to the actual test, and procedure or registration being performed. Adheres to AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. The value you'll bring to the team: Responsible for review of chemotherapy regimen/treatment orders and determines insurance benefits and authorization requirements.Reviewsclinicaldatasuchaspatientpathologyreports,scans,laboratoryresults,priortreatments,matching against insurance payor and/or National Comprehensive Cancer Network (NCCN) guidelines. Ensures specified medical terms, diagnosis, medication codes and supporting clinical documentations are met. Utilization review to facilitate the sending of clinical information in support of the authorization to payor or third-party administrators, as assigned. · Reviews medical records in detail to confirm the treatment is supported by approved medical studies by reputable oncology/hematologystudies.Stayscurrentonpayerpreferenceforbiosimilardrugsavailable.Ensurespatientordersare changed accordingly if biosimilar drug is preferred. Ensures that each treatment is coded, reviewed, and financially cleared based on the patient insurance requirements. ·VerifiesmedicalnecessityinaccordancewithCentersforMedicare&MedicaidServices(CMS)standardsby reviewingguidelinesandcommunicatesrelevantcoverage/eligibilityinformationtothepatient.Alertsphysicianofficesto issues with verifying insurance. Responsible for communicating to service line partners of situations where medical necessity is not met to include review of journal articles, compendia and/or peer review to justify medical necessity approval. · Reviews clinical records when following up on authorization request directly with a payor. Escalates peer to peer (insurance company physician requests to speak to ordering physician) requests to physician offices and assists in schedulingpeertopeerrequestswiththeofficeandthepayertoensureanauthorizationdecisionismadepriortodateof service. ·Obtainsinitialandsubsequentpre-authorizationforchemotherapytreatments,aswellasresearchprotocols,onallnew andexistingpatientsandnotesapprovalsintheelectronicmedicalrecord.Uploadstreatmentsupportingdocumentation packet to the electronic medical record for Revenue Cycle billing and coding teams. ·Contactsinsurancecompaniesbyphone,fax,onlineportal,andotherresourcestoobtainandverify insurance eligibilityandbenefitsanddetermineextentofcoveragewithinestablishedtimeframebeforescheduledappointmentsand during or after care for unscheduled patients. ·Obtains pre-authorizations from third-party payers in accordance with payer requirements and within established timeframe before scheduled appointments and during or after care for unscheduled patients. Accurately enters required authorization information in AdventHealth systems to include length of authorization, total number of visits, and/or units ofmedication.Convertordersanddosagetoensuretheproperauthorizationisrequestedandapproved,basedontheunits the payer has given. Qualifications The expertise and experiences you'll need to succeed: · High School Grad or Equivalent · One (1) year experience in Oncology related business operations within specialty pharmacy or insurance verification, payor reimbursement guidelines, and/or authorization submission. Familiarity with medical terminology and concepts. Working knowledge with third party insurance administrators' authorization and clinical care processes. · One year of customer service experience This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location. Category: Physician Services Organization: AdventHealth Georgia Schedule: Part-time Shift: 1 - Day Req ID: 24026608 We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.