Clinical Reviewer

Overview:



Texas Oncology requires new employees to be fully vaccinated for COVID-19 as defined by the CDC, subject to applicable, verified accommodation requests.

Texas Oncology is looking for a Clinical Insurance Reviewer to join our team ! This position will support the Paris location .

Texas Oncology i s the largest community oncology provider in the country and has approximately 600 providers in 220 sites across Texas and southeastern Oklahoma. Our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. Our mission is still the same today-at Texas Oncology, we use leading-edge technology and research to deliver high-quality, high-touch, evidence-based cancer care to help our patients achieve "More breakthroughs. More victories." ® in their fight against cancer. Today, Texas Oncology treats half of all Texa ns diagnosed with cancer on an annual basis.

Why work for us?

Come join our team that is responsible for helping lead Texas Oncology in treating more patient diagnosed with cancer than any other provider in Texas. W e offer our employees a competitive benefits package that includes Medical, Dental, Vision, Life Insurance, Short-term and Long-term disability coverage, a generous PTO program , a 401k plan that comes with a company match, a Wellness program that rewards you practicing a healthy lifestyle , and lots of other great perks such as Tuition Reimbursement, an Employee Assistance program and discounts on some of your favorite retailers.

What does the Clinical Insurance Reviewer do?

Under general supervision, reviews chemotherapy regimens in accordance to reimbursement guidelines. Obtains necessary pre-certifications and exceptions to ensure no delay in reimbursement of treatments. Researches denied services and alternative resources to pay for treatment. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.
Responsibilities:

• Reviews, processes and audits the medical necessity for each patient chemotherapy treatment and documentation of regimen relative to pathway adherence.
• Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with particular insurance plans. Provides prompt feedback to physicians and management regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.
• Updates coding/payer guidelines for clinical staff. Tracks pathways and performs various other business office functions on an as needed basis
• Obtains insurance authorization and pre-certification specifically for chemotherapy services. Works as a patient advocate and functions as a liaison between the patient and payer to answer reimbursement questions and avoid insurance delays.
• Researches additional or alternative resources for non-covered chemotherapy services to prevent payment denials. Provides a contact list for patients community resources including special programs, drugs and pharmaceutical supplies and financial resources.
• Maintains a good working knowledge of chemotherapy 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:

• 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.
  

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 handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. 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. Work may require minimal travel by automobile to office sites.