Medical Insurance Specialist

Obtains precertification, authorization or referral from insurance companies for patients receiving care in the Cancer Center. Records all precertifications, authorizations, and referrals in the appropriate software system. Coordinates with clinicians and clerical staff regarding any issues regarding patient insurance status.

• Reviews clinical and non-clinical data which includes medical terms and diagnosis or procedure codes in order to obtain preauthorization or precertification or oncology, hematology, chemotherapy, and radiation treatments.
• Has comprehensive knowledge and understanding of payer policies and criteria as related to preauthorization and precertification.
• Works with the Financial Navigator /Counselor to educate patients on their health insurance plan, as needed.
• Responsible for obtaining Provider referrals from individual PCP, Medicaid, VA and other primary insurances after the initial provider referral by registration obtained.
• Make appropriate changes to individual’s demographic and insurance information on internal systems when needed.
• Knowledge of CPT codes for procedures/drugs to determine whether or not precertification is required.
• Responsible for getting daily list of patient’s insurance that may or may not require pre-certification or pre-authorization for chemotherapy support
• Verify that insurance does or does not cover chemotherapy and radiation treatments.
• Verify that the correct contract and group number is in Meditech in order to obtain pre authorization or pre certification.
• Verify that the facility is in network or out of network in relationship to authorization requirements.
• Enters preauthorization or precertification numbers into Aria and Expanse.
• Communicates with internal and external imaging departments as needed for proper follow through of scheduling/precertification of the Cancer Center patient’s imaging schedules.
• Communicates with internal pharmacy for proper follow through on prior authorizations for oncology and hematology medications.
• Assist other coworkers with their tasks to even out workload.
  
  
  

DCH Standards

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.
  
  
  

Must be a High school graduate. Healthcare experience required, with minimum of 2 years of Oncology experience preferred. Clerical skills with demonstrated proficiency in keyboarding/computer use. Must be self-motivated and possess the ability to work effectively in an independent environment. Ability to work well with the public, physicians, insurance companies and other hospital staff in a courteous and professional manner. Must be able to read, write legibly, speak, and comprehend English. Experience with obtaining preauthorization and working with insurance companies preferred. Knowledge of medical terminology preferred.

WORKING CONDITIONS

WORK CONTEXT

Frequent interaction with others, in person or by telephone, including those that may be discourteous or unpleasant in content. . Extensive use of computers and computer systems Extensive documentation requirements requiring attention to detail.

PHYSICAL

Perform light work with minimal force exerted.

Talking, hearing, bending ,walking, lifting, repetitive motion, standing, and/or using hands to handle, control, or feel objects, tools or controls. Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.

Must be able to perform the duties with or without reasonable accommodation.

Hearing and vision must be normal or corrected to within normal range.

Physical presence onsite is essential.