Serves as an expert in initiating and obtaining infursion service pre-authorizations through review and submission of clinical, demographic and insurance information.  This function is critical in supporting complex time sensitive patient care and reimbursement of high dollar services in a highly dynamic environment.

• Understands the major cancer types and treatment protocols, drugs and regimens.

• Able to effectively communicate via phone, email and via system messaging with physicians, nurse practitioners, physician assistants, nurses, patients, insurance companies and infusion oncology administration.

• Initiates pre-authorization for infusion services with insurance companies by reviewing and submitting supporting medical documentation to support various treatment regimens.

• Able to escalate and interact with medical staff on a case by case basis to obtain additional supporting clinical documentation to support insurance company prior authorizations.

• Provides prompt feedback to physicians and management regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.

• Effectively communicates unsupported medical necessity, special requirements and/or restrictions to providers and administration

• Review and evaluate oncology procedures to assure the appropriateness and medical necessity of medication use based on NCCN guidelines

• Able to track and follow up on multiple authorizations for the same patients for multiple drugs that expire and must be renewed at different points in time.

• Able to work with insurance providers to determine coverage, benefit limitations and patient financial responsibility prior to all patients scheduled treatments.

• Willingness to learn about new treatment options in a dynamic insurance environment and be able to adapt and overcome new administrative insurance barriers.

Preferred Criteria

• Knowledge of CPT/ ICD10

• Bachelor’s Degree from a recognized college or significant work experience in lieu of degree

Required Criteria

• High School Diploma or GED

• Knowledge of Commercial/ Governemnt coverage

• 5 years related experience

• Knowledge of third party reimbursement (contracting and non-contracting) and eligibility requiremnets for the all subsidy programs

• Knowledge/ ability to obtain insurance benefit verfication