Under the general supervision of the Administrative Manager and per the established policies and procedures, the Insurance specialist is responsible for overseeing the Radiation Oncology authorization process. Working very closely with nurses, physicians and other clinical staff members to ensure a quality-based, customer-oriented flow of work throughout the practice. Serves as the subject matter expert in radiation oncology authorizations, and is the resource person for support staff, intake manager and all clinical staff.

Understands all insurance medical policies, including managed care plans, HMO's and unusual coverage. Determines eligibility and obtains Prior authorizations and Pre-determination from third party payers for all types of radiation procedures (i.e. Proton, IMRT, VMAT, SRS, SBRT, 3D). Requires understanding of coordination of benefits, and references medical policies for coverage. Provides information to patients regarding eligibility for radiation services.

* Responsible for locating medical policy on insurance website and determining eligibility using external resources

* Responsible for providing necessary information as required by third party payer, and completing required pre-authorization forms (payer specific)

* Will set up peer to peer review with the physician and third party, documenting outcome

* Responsible for obtaining a letter of medical necessity for radiation treatment from the physician

* Informs patient and physician of any potential problems with coverage or authorization prior to scheduling appointment

* Responsible for obtaining all authorizations, in an appropriate time frame. Must have great time management skills as well as great follow through to see the authorization from start to finish

* Will require an understanding of radiation oncology CPT codes for treatment authorization, as well as ICD10 codes for diagnosis

* Will be required to work very independently and function at a very high level in order to complete pre-auth and pre-D form submission

* Attends Proton rounds every Tuesday and communicates to physicians any potential insurance barriers

* Responsible for updating "Whiteboard" with authorization information

* Attends weekly managed care meetings

* Will work to obtain an estimate of charges for the international office or at any patient request

* Maintains excellent records (electronic and otherwise) of all referrals and inquiries.

* Participates in an open line of communication with the team (adult and Pedi) to collaborate, exchange information and review patient scheduling status

* May be required to provide clinical documentation for insurance review

* Will be responsible for working the RO Insurance mailbox

* Responsible for working any patient denial and appeal

* Responsible for working Epic work queues

* Responsible for accuracy and quality of individual work assignment, and a willingness to assist other team members validating the importance and value of team success

QUALIFICATIONS:

* Associates Degree or higher preferred

* Minimum of 5 years of healthcare experience

* Knowledge of third party payers a plus

* Knowledge of ICD10 and CPT coding a plus

* Must have basic knowledge of Anatomy and Physiology

* Medical terminology and medical coding knowledge desired.

* Excellent customer service and communication skills

* Good organizational skills required to handle multiple tasks in a busy environment

* Basic knowledge of Outlook, word and excel. Will train in department system.

* Ability of work independently and prioritize work.

* Excellent customer service and communication skills

* Good organizational skills required to handle multiple tasks in a busy environment

Willingness to continually learn and grow as a member of a Team and Department

The right candidate must have a positive attitude, quick mind, and thrive with working under strict time lines.