Responsible for review and coding of chemotherapy regimen/treatment orders. Review of structured clinical data matching against insurance payor and/or National Comprehensive Cancer Network (NCCN) guidelines. Ensuring specified medical terms, diagnosis, medication codes and supporting clinical documentations are met. Utilization review to facilitate the sending of clinical information in support of the authorization to payor or third-party administrators, as assigned. Responsible for communicating to service line partners of situations where medical necessity is not met to include review of journal articles, compendia and/or peer review to justify medical necessity approval.
Contacts insurance companies by phone, fax, or online portal to obtain insurance benefits, eligibility, and authorization information. Accurately enters required authorization information in AdventHealth systems to include length of authorization, total number of visits, and/or units of medication. Responsible for denial notification to clinical counterparts, meeting strict timely notification standards. Completes patient estimates for chemotherapy regimen/treatment plan to include medication units, deductible, coinsurance and out of pocket maximums. Obtains PCP referrals when applicable.
Meets or exceeds audit accuracy and productivity standard goals determined by Pre-Access leadership, while meeting timeline standards established by leadership for all patient services. Ensures integrity of patient accounts by working error reports as requested by management and entering appropriate and accurate data. Provides timely and continual coverage of assigned work area in order to offer prompt service to partners. Assists with authorization initiation process if needed. Meets attendance requirements, and maintains schedule flexibility, as required. Exhibits effective time management skills by monitoring time and attendance to limit use of unauthorized overtime.
Uses utmost caution that obtained benefits, authorizations, and pre-certifications are accurate according to the actual chemotherapy regimen/treatment and procedures being performed. Ensures all benefits, authorizations, pre-certifications, and financial obligations of patients, are documented on account memos, clearly, accurately, precise, and detailed to ensure expeditious processing of patient accounts. Conducts diligent follow-up on outpatient and inpatient authorization accounts with third party payers to minimize authorization related denials through phone calls, emails, faxes, and payer websites, updating documentation as needed.
Maintains a close working relationship with clinical partners, and ancillary departments to ensure continual open communication between clinical, ancillary, and Patient Access & Patient Financial Services departments. Monitors team mailbox, e-mail inbox, faxes, and phone calls responding to all related Pre-Access account issues, within defined time frames. Exhibits effective time management skills and maintains flexibility by being available for all partners and team. May assists team with reports and projects to maintain team and individual productivity standards and goals.
What Will You Need:
EDUCATION AND EXPERIENCE REQUIRED:
One (1) year experience in Patient Financial Services, Patient Access, Customer Service or related area (registration, finance, collections, customer service, medical office, or contract management)
EDUCATION AND EXPERIENCE PREFERRED:
Associate degree and/or higher-level education or completed coursework
Two (2) yearsâ™ experience in Oncology related business operations within
specialty pharmacy, insurance verification, payor reimbursement guidelines, and/or authorization submission. Familiarity with medical terminology and concepts. Working knowledge with third party insurance administrators authorization and clinical care processes.
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
Clinically relevant certification such as Medical Assistant, Patient Care Tech or Pharmacy Tech
The Pre-Access Infusion Financial Clearance Specialist, under general supervision, maintains performance standards appropriate to area by obtaining account benefits and/or verifying authorizations are in place for all chemotherapy regimens and treatments, and meeting timeline standards established by leadership for all patient services. Meets or exceeds department audit accuracy and productivity standard goal. Uses utmost caution that obtained benefits, authorizations, and/or pre-certifications are accurate according to the actual test, and procedure or registration being performed. Adheres to AdventHealth Corporate Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.