About the position

Comprehensive Cancer Centers of Nevada (CCCN) is seeking a Remote Insurance Reviewer - Clinical (Treatment Prior Authorization Specialist) in Southern Nevada only. Under general supervision, this role reviews all orders for prior authorization, including diagnostic radiology, outside consultations and procedures, outside specialty laboratory, in-house treatment, radiation, and external procedures to comply with reimbursement guidelines and authorization requirements. The specialist obtains necessary authorizations, pre-certifications, or predeterminations to prevent delays in patient care and relays denied services, providing next level steps for denial or alternative recommendations to the Provider for ordered testing. This position supports and adheres to the US Oncology Compliance Program, including the Code of Ethics and Business Standards.

Responsibilities

• Reviews, processes, and audits the medical necessity for each patient’s external diagnostic order in accordance with the benefits of the plan, prior authorization, or predetermination processes and NCCN guidance, when appropriate.
• 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 any non-covered or repeated denials, and payer issues with non-covered services requested.
• Updates or contributes coding/payer guidelines for clinical staff.
• Records any trends from the payors and performs various other business office functions on an as needed basis.
• Electronically submits authorization or verifies that the ordered service is a covered benefit of the health plan.
• Uses multiple electronic medical records (EMR) payor portals and third-party online web portals to submit.
• Ability to work in a paperless environment using digital documents.
• Works as a patient advocate and functions as a liaison between the patient and payer to answer reimbursement or authorization questions and avoid insurance delays.
• Maintains a good working knowledge of 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.

Requirements

• High school degree or equivalent.
• Minimum three (3) years medical insurance verification, and authorization required.
• Experience using electronic medical record portals.

Nice-to-haves

• Associates degree in Healthcare, LPN state license and registration preferred.

Benefits

• excellent benefits
• a team environment
• professional development
• the chance to be part of a nationwide network dedicated to fighting the war against cancer