Job Description:

I. Audit

• Completing QA audits for their processes by following the QIP

• Providing feedback to team members on all errors

• Escalating any anomalies / trends / Compliance issues

• Performing the actual production work to keep abreast of the latest updates and practical scenarios

• Participating in client calls to capture process updates and monitoring compliance to the updates

II. Process

• Contact insurance carriers to verify patient’s insurance eligibility, benefits, and requirements.

• Request, track, and obtain pre-authorization from insurance carriers within time allotted for medical and services.

• Review, request, follow up and secure authorizations for high dollar cost oncology chemotherapy drugs.

• Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations.

• Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.

• Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.

• Prioritize the incoming authorizations by level of urgency to the patient.

• Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting in the EHR as appropriate.

• Respond to clinical questions regarding payer medical policy guidelines

Qualifications:

• Must hold an active PHRN license (not a USRN license holder)

• Relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is a must

• Strong familiarity with EPIC, MCG, or InterQual guidelines required

• Demonstrated job stability, with a consistent employment history and minimal transitions