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Pre-Access Infusion Benefits and Authorization Specialist-ONCOLOGY

1 month ago

Hinsdale, United States Discover Vanderbilt University Medical Center Full time

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 other injection/infusion treatments. Meet 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. Responsible for review of chemotherapy regimen and other injection/infusion treatment orders and determines insurance benefits and authorization requirements. Reviews clinical data such as patient pathology reports, imaging, laboratory results, prior treatments, 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/hematology studies. Stays current on payer preference for biosimilar drugs available. Ensures patient orders are changed accordingly if biosimilar drug is preferred. Ensures that each treatment is coded, reviewed, and financially cleared based on the patient insurance requirements. Verifies medical necessity in accordance with Centers for Medicare & Medicaid Services (CMS) standards by reviewing guidelines and communicates relevant coverage/eligibility information to the patient. Alerts physician offices to 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. #J-18808-Ljbffr