Pre-Access Oncology Specialist, 250 E. Liberty, 7:30a-4:30p

Primary Location:

Med Plaza II - UMC

Address:

250 E Liberty Louisville, KY 40202

Shift:

First Shift (United States of America)

Job Description Summary:

UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehab Institute and Brown Cancer Center.

With more than 12,000 team members-physicians, surgeons, nurses, pharmacists, and other highly skilled health care professionals-UofL Health is focused on one mission: delivering patient-centered care to each patient every day.

Job Description:

The Pre-Access Oncology Specialist will be responsible for verifying accurate insurance, obtaining, or verifying authorization, referrals, or precertification, checking medical necessity, refers concerns about patient estimates to financial clearance team, keeping open conversations with patient and patient's advocate for inpatient and outpatient procedures.

The Pre-Access Oncology Specialist will coordinate patient orders received from physician offices and internal ancillary departments assuring appropriate distribution to the servicing department. Reviews 100% of all scheduled procedure orders for accuracy including physician signature, test/procedure to be performed, date and diagnosis, calls physician office to clarify order as needed, and indexes order to the account.

Coordinate patient encounter utilizing multiple system applications: various registration applications, clinical operating systems, eligibility verification systems, medical necessity applications, scanning repository.

Essential Functions:

• Contacts insurance plans/payers to determine eligibility and obtain coverage and benefit information. Pre-Access Oncology Specialist are to start cases over the phone, follow up, provide, and fax any clinical notes pertaining to the case to the insurance payors.
• Meets or exceeds productivity standards in the completion of daily assignments and accurate production.
• Makes changes to demographic information as necessary to produce a clean patient statement.
• Maintains consistent communication with payers, obtains any necessary referrals, treatment approvals for BMT, Med Oncology and Rad Oncology. Obtain approvals for Inpatient and Outpatient services. Provides specifically requested information to payer to obtain approvals/authorizations; assists in the preparation of appeals for denials received from Med Oncology, Rad Oncology and/or Pharmacy.
• Document findings thoroughly and accurately and enters all authorizations that are obtain into billing system along with the correct ICD-10 and CPT code to ensure payment. This includes any add on procedures for same or next day services. Also adds authorization in electronic medical record.
• Provide Utilization Review, Admissions, University Medical Associates, and Diagnostic Radiology with all necessary referral/authorizations and any additional medical information relating to the patient.
• Assists admissions/billing departments with any insurance updates, concerns, and denials.
• Request and follow up with any retro/appeal to obtain payment.
• When procedures are changed by requesting provider, Pre-Access Oncology Specialist calls insurance payers to obtain, change or update approvals in a timely manner to take care of the patient. This will increase patient satisfaction and health of the patient.
• Pre-Access Oncology Specialist provides clinical information over the phone to nurse reviewer to prevent peer to peer reviews. If a peer-to-peer review is needed, Pre-Access Oncology Specialist will call payer to schedule. Physicians, and physician's nurse will be notified. Case number with date and time are provided to the physician for peer-to-peer review.
• Understands payer processes for intravenous medication/infusion authorizations and improves/maintains oncology compliance with payer policies and procedures.
• Verifies benefits for patients with intravenous medications/infusions ordered by Medical Oncologists. Notifies patient if benefits are not in-network. Refers patient to an in-network facility if necessary. Works closely with admissions and the business office as needed to accept out-of-network benefits when possible.
• When necessary, Pre-Access Oncology Specialists called the insurance company to initiate a Gap Exemption approval and obtain approval before patient comes to appointment.
• Reviews intravenous medication orders against specific payer's medical policy and requests treatment authorizations based on the payer's authorization criteria.
• Triage patients who may be denied treatment based on off-label indications (for Medicare patients review against FDA-approved labeling or compendia listing for approval indications) into manufacturer-sponsored patient assistance programs (per Oncology pharmacy).
• Assists with denials/appeals by providing patient specific documentation demonstrating patient improvement in condition and/or at least 2 clinical research articles demonstrating efficacy of ordered medications for patient's diagnosis.
• Responds to third party payer requests for clinical information including: laboratory test results, progress notes, tumor staging reports, etc. as requested on a case-by-case basis.
• Participates in meetings (as appropriate) relating to coding, billing, reimbursement, denials, etc. for intravenous medications and infusions.
• Maintains current knowledge base of clinical information regarding each patient's diagnosis and treatment plan to communicate medical updates effectively with payers and justify payment of services.
• Educates physicians and nursing staff on the intravenous medication/infusion authorization process and payer requirements.
• Answer and respond to external and internal phone calls in a timely manner. Check and respond to emails in a timely and professional manner.
• Manages all orders received by fax, physician EMR or other sources and scans into appropriate hospital electronic patient medical record.
• Complies with all department and hospital policies and procedures. Maintains a working knowledge of department, hospital, and state laws (HIPPA) governing the release of information. Strictly adheres to safeguarding and preserving the confidentiality of medical records and patient information.
• Complies with local, state, and federal rules and regulations, and the requirements of accrediting bodies.
• Completes routine assignments and special projects as directed.
• Prioritizes work according to department and hospital need.
• Attends and participates in department and hospital meetings, in-services, and quality improvement teams.
• Contributes to the accomplishment of department and hospital objectives.
• Projects a positive personal and professional image of the Pre-Access Specialist, Patient Access department, and hospital always, under all circumstances.
• Knowledgeable of clinical information regarding each patient.
• Communicate medical updates effectively with payers and justify payment of services.
• Must remain current and knowledgeable of LMRP/LCD and NCCN guidelines.

CLINICAL TRIAL RESEARCH/GENOTYPE/FOUNDATION ONE RESPONSBILITIES

• Acquire authorization for Clinical Trials/Genotype and Foundation One.
• Follow up with pharmacy for drug replacement on denials and provide update of drug use.

Other Functions:

• Maintains compliance with all company policies, procedures, and standards of conduct
• Complies with HIPAA privacy and security requirements to always maintain confidentiality
• Performs other duties as assigned

Additional Job Description:

Education:

• High School Diploma or equivalent (required)

Experience:

• Excellent organizational, oral & written communication skills (required)
• Clinical & Medical terminology (required)
• At least three years' experience in medical authorization (preferred)

Job Competency:

Knowledge, Skills, and Abilities critical to this role:

• Must be dependable, professional and a team player
• Critical thinking skills
• Solid oral and written communication skills
• Ability to multi-task and be flexible with job demands
• Energetic, motivated individual that connects well with people

Additional Responsibilities:

• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor always
• Maintains confidentiality and always protects sensitive data
• Adheres to organizational and department specific safety standards and guidelines
• Works collaboratively and supports efforts of team members
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff, and the broader health care community