Advocate Aurora Health
Prior Authorization Representative, Oncology
Advocate Aurora Health, Wake Forest, North Carolina, us, 27588
Department:
10549 Wake Forest Baptist Medical Center - Pre Authorization Insurance for Treatment
Status:
Full time
Benefits Eligible:
Yes
Hou
rs Per Week:
40
Schedule Details/Additional Information:
Varies
Pay Range $21.45 - $32.20
Prior Authorization Representative, Oncology
40 hours per week, day shift
JOB SUMMARY:
The Prior Authorization Representative - Oncology is responsible for all aspects involved in obtaining highly complex authorizations and predeterminations for a multitude of In-patient and Out-patient Oncology Services prior to treatment. The Prior Authorization Representative must be knowledgeable and have a thorough understanding of Commercial and Government payers with regards to Coordination of Benefits, Authorization guidelines, Pharmacy and Medical Benefit variances, as well as Medical Necessity Policies. The Prior Authorization Representative is responsible for reading and interpreting various complex medical records to obtain authorizations for requested services and treatment plans. Communication with clinic staff, providers, pharmacists, and insurance companies is essential to ensure completed peer reviews, relay updated medical and specialty drug policies, and appeals. Review reimbursement and denials to ensure all denials and/or contractual adjustments have been reviewed and assess opportunities for retro-active authorizations/appeals and determine root cause analysis.
EDUCATION/EXPERIENCE:
Bachelor's degree or 3 years of experience. Experience working in health system, medical office, insurance industry or equivalent preferred. Prior authorization, Coding and/or Oncology Services experience preferred.
LICENSURE, CERTIFICATION, and/or REGISTRATION:
N/A
ESSENTIAL FUNCTIONS: Assess time sensitive work queues to obtain highly complex authorizations including IP/OP Chemotherapy, Radiology, specifically related to Oncology treatment plans, IP/OP Surgeries, Molecular and Genetic Laboratory Testing. Documents prior authorization activities appropriately and communicates necessary information to providers, care team and third party payers. Interpret medical records to determine initial and disease progression to prove medical necessity for ordered services and complete on-line clinical requests for advance authorization. Review and/or edit ICD, CPT, and HCPCS codes that substantiate provider's professional services for ambulatory health records including ambulatory visits and procedures, maintaining established departmental accuracy and productivity standards. Works closely with denial team to provide documentation for appeal. Review and address monthly denials for Chemotherapy Drugs, Molecular Labs and surgeries with payers and Denial Management Teams. Reviews all department reimbursements (professional and hospital) to ensure that contractual adjustments and denials are appropriate and have been appealed when necessary. Reviews for denial trends so adjustments may be made when appropriate by coding staff.
SKILLS & QUALIFICATIONS: Excellent interpersonal skills and ability to establish strong working relationships with contacts inside and outside the Medical Center Strong oral and written communication skills to effectively interact with leadership team, patients, physicians and care team on a daily basis Strong time management skills are required to prioritize assignments and meet pre-determined deadlines Ability to anticipate, recognize and meet the needs of patients and their families while showing respect and sensitivity for their individual needs Ability to use initiative, judgement, and discretion in daily work Analytical skills Microsoft Word and/or Excel skills WORK ENVIRONMENT:
Clean, comfortable, office environment Subject to varying and unpredictable situations Subject to many interruptions and stressful situations Our Commitment to You:
Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so you can live fully at and away from work, including:
Compensation
Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more
Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program
About Advocate Health
Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation's largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
10549 Wake Forest Baptist Medical Center - Pre Authorization Insurance for Treatment
Status:
Full time
Benefits Eligible:
Yes
Hou
rs Per Week:
40
Schedule Details/Additional Information:
Varies
Pay Range $21.45 - $32.20
Prior Authorization Representative, Oncology
40 hours per week, day shift
JOB SUMMARY:
The Prior Authorization Representative - Oncology is responsible for all aspects involved in obtaining highly complex authorizations and predeterminations for a multitude of In-patient and Out-patient Oncology Services prior to treatment. The Prior Authorization Representative must be knowledgeable and have a thorough understanding of Commercial and Government payers with regards to Coordination of Benefits, Authorization guidelines, Pharmacy and Medical Benefit variances, as well as Medical Necessity Policies. The Prior Authorization Representative is responsible for reading and interpreting various complex medical records to obtain authorizations for requested services and treatment plans. Communication with clinic staff, providers, pharmacists, and insurance companies is essential to ensure completed peer reviews, relay updated medical and specialty drug policies, and appeals. Review reimbursement and denials to ensure all denials and/or contractual adjustments have been reviewed and assess opportunities for retro-active authorizations/appeals and determine root cause analysis.
EDUCATION/EXPERIENCE:
Bachelor's degree or 3 years of experience. Experience working in health system, medical office, insurance industry or equivalent preferred. Prior authorization, Coding and/or Oncology Services experience preferred.
LICENSURE, CERTIFICATION, and/or REGISTRATION:
N/A
ESSENTIAL FUNCTIONS: Assess time sensitive work queues to obtain highly complex authorizations including IP/OP Chemotherapy, Radiology, specifically related to Oncology treatment plans, IP/OP Surgeries, Molecular and Genetic Laboratory Testing. Documents prior authorization activities appropriately and communicates necessary information to providers, care team and third party payers. Interpret medical records to determine initial and disease progression to prove medical necessity for ordered services and complete on-line clinical requests for advance authorization. Review and/or edit ICD, CPT, and HCPCS codes that substantiate provider's professional services for ambulatory health records including ambulatory visits and procedures, maintaining established departmental accuracy and productivity standards. Works closely with denial team to provide documentation for appeal. Review and address monthly denials for Chemotherapy Drugs, Molecular Labs and surgeries with payers and Denial Management Teams. Reviews all department reimbursements (professional and hospital) to ensure that contractual adjustments and denials are appropriate and have been appealed when necessary. Reviews for denial trends so adjustments may be made when appropriate by coding staff.
SKILLS & QUALIFICATIONS: Excellent interpersonal skills and ability to establish strong working relationships with contacts inside and outside the Medical Center Strong oral and written communication skills to effectively interact with leadership team, patients, physicians and care team on a daily basis Strong time management skills are required to prioritize assignments and meet pre-determined deadlines Ability to anticipate, recognize and meet the needs of patients and their families while showing respect and sensitivity for their individual needs Ability to use initiative, judgement, and discretion in daily work Analytical skills Microsoft Word and/or Excel skills WORK ENVIRONMENT:
Clean, comfortable, office environment Subject to varying and unpredictable situations Subject to many interruptions and stressful situations Our Commitment to You:
Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so you can live fully at and away from work, including:
Compensation
Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more
Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program
About Advocate Health
Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation's largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.