Insurance Prior Authorization Specialist - Remote (Southern Nevada Only)

While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Orders can include but are not limited to diagnostic radiology, outside consultations and procedures, outside specialty laboratory, in-house treatment, radiation and external procedures to comply with reimbursement guidelines and authorization requirements.

Overview:

At Comprehensive Cancer Centers of Nevada (CCCN) a distinguished team of doctors, researchers, nurses, and healthcare professionals have provided patients with groundbreaking treatments on the healing edge of medicine for over 50 years.  Our team provides the most effective treatments, both existing and emerging, to diagnose and successfully treat cancer and blood disorders. We support this goal with state-of-the-art facilities across Southern Nevada, all of which integrate the latest diagnostic, therapeutic, and research capabilities.  CCCN is dedicated to patient-centered care, advancing innovation, discovery, and improving outcomes.  Motivated, caring professionals are encouraged to join us.

 

Career Opportunity:
Comprehensive Cancer Centers of Nevada is seeking a Remote Insurance Reviewer - Clinical (Treatment Prior Authorization Specialist) in Southern Nevada only.

 

SCOPE:
Under general supervision, reviews all orders for prior authorization. Orders can include but are not limited to diagnostic radiology, outside consultations and procedures, outside specialty laboratory, in-house treatment, radiation and external procedures to comply with reimbursement guidelines and authorization requirements. Obtains necessary authorizations, pre-certifications or predeterminations to prevent delays in patient care. Relays denied services and provides next level steps for denial or alternative recommendation to the Provider for ordered testing.  Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

Responsibilities:

ESSENTIAL DUTIES AND 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.
  
  

Qualifications:

MINIMUM QUALIFICATIONS:

 

• High school degree or equivalent.
• Associates degree in Healthcare, LPN state license and registration preferred.
• Minimum three (3) years medical insurance verification, and authorization required.
• Experience using electronic medical record portals.
  
  

COMPETENCIES:

• Uses Technical and Functional Experience: Possesses up to date knowledge of the profession and industry; is regarded as an expert in the technical/functional area; accesses and uses other expert resources when appropriate.
• Demonstrates Adaptability: Handles day to day work challenges confidently; is willing and able to adjust to multiple demands, shifting priorities, ambiguity and rapid change; shows resilience in the face of constraints, frustrations, or adversity; demonstrates flexibility.
• Uses Sound Judgment: Makes timely, cost effective and sound decisions; makes decisions under conditions of uncertainty.
• Shows Work Commitment: Sets high standards of performance; pursues aggressive goals and works efficiently to achieve them.
• Commits to Quality: Emphasizes the need to deliver quality products and/or services; defines standards for quality and evaluated products, processes, and service against those standards; manages quality; improves efficiencies.
  
  

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Requires full range of body motion including, manual and finger dexterity, and eye-hand coordination. Occasionally lifts and carries items weighing up to 40 lbs. Requires corrected vision and hearing to normal range.

WORK ENVIRONMENT:

The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations, and other conditions common to an oncology/hematology clinic environment. Work will involve in-person interaction with co-workers and management and/or clients on occasion. Work may require minimal travel by automobile to office sites. Position is a work from home position with training and instruction to occur at a designated office site for a satisfactory amount of time before the employee can transition to a work from home environment. Employee will provide access to reliable, high-speed internet, ergonomic workspace, and chair, and you agree to use this designated workspace for your work from home purposes.  Home Office workspace (e.g., furniture, lighting, etc.) must be provided at your own expense. Home Office, you propose has a suitable workspace to conduct business with minimal background noise and distractions during your work hours.

 
Ready For Your Next Career Challenge?  We’d Love to Hear from You!
If you possess the above qualifications and a desire to make a difference, we invite you to submit your resume and apply.  In addition to a great career opportunity, we offer excellent benefits, a team environment, professional development, and the chance to be part of a nationwide network dedicated to fighting the war against cancer.  To apply please click on the Apply Now link. 
 
The US Oncology Network is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. This employer participates in E-Verify.