Under the general supervision of the Administrative Manager and according to the established policies and procedures, the Insurance specialist is responsible for overseeing the Radiation Oncology authorization process. Working very closely with nurses, physicians and other clinical staff members to ensure a quality-based, customer-oriented flow of work throughout the practice. Handles all aspects of insurance issues and assists patients with all the financial aspects of their visit. Serves as the subject matter expert in radiation oncology authorizations, and is the resource person for support staff, intake manager and all clinical staff.
- The Insurance Specialist serves as departmental expert resource and representative on authorizations for all types of radiation treatments. Working autonomously on each individual patient authorization for the entire course of treatment, ensuring that things are coded correctly, and expedited as quickly as possible so that a patient's course of treatment is not delayed. Will also be responsible for overseeing the hospital patient denials and triaging to the appropriate staff, instructing them on the proper submission of documentation and forms to appeal, and achieve success in overturning the denial. This involves a very high level of understanding of insurance medical policies, as well as radiation oncology procedures and coding.
PRINCIPAL DUTIES AND RESPONSIBILITIES :
Understands all insurance medical policies, including managed care plans, HMO's and unusual coverage.Determines eligibility and obtains Prior authorizations and Pre-determination from third party payers for all types of radiation procedures (i.e. Proton, IMRT, VMAT, SRS, SBRT, 3D). Requires understanding of coordination of benefits and references medical policies for coverage.Provides information to patients regarding eligibility for radiation services.Responsible for locating medical policy on insurance website and determining eligibilityResponsible for providing necessary information as required by third party payer, and completing required pre-authorization forms (payer specific)Sets up peer to peer review with the physician and third party, documenting outcomeAssists in writing Letter of medical necessity for radiation treatmentInforms patient and physician of any potential problems with coverage or authorization prior to scheduling appointmentResponsible for obtaining all authorizations, in an appropriate time frame. Must have great time management skills as well as great follow through to see the authorization from start to finishWill require an understanding of radiation oncology CPT codes for treatment authorization, as well as ICD10 codes for diagnosisWill be required to work very independently and function at a very high level in order to complete pre-auth and pre-D form submission, understanding that a patient will receive a bill if not completed correctlyResponsible for post service review and appeal of denied cases.Understanding of Epic claim review, liability buckets and billing transactions (both Professional billing and hospital billing)Attends Proton rounds every Tuesday and communicates to physicians the insurance and start date availability information at RoundsDemonstrates a clear efficient manner utilizing patient scheduling spreadsheet; responsible for optimizing patient flow and utilization of proton treatment slots.Responsible for updating "Whiteboard" with authorization informationAttends weekly managed care meetingsAttends monthly denial meetings and researches payer denial and reports finding to manager in timely mannerResponsible for Epic WQ'sAssists with department billing and charge reviewWill work to obtain an estimate of charges for the international office or at any patient requestMaintains excellent records (electronic and otherwise) of all referrals and inquiries.Participates in an open line of communication with the team (adult and Pedi) to collaborate, exchange information and review patient scheduling statusWorks with staff of MGH International office to facilitate the transport, evaluation and treatment of international patientsResponsible for accuracy and quality of individual work assignment, and a willingness to assist other team members validating the importance and value of team successEDUCATION :
High School Diploma or GED required. Associates Degree or higher preferred
EXPERIENCE :
Minimum of 5 years of healthcare experienceKnowledge of third party payers Knowledge of ICD10 and CPT coding a plusMust have basic knowledge of Anatomy and Physiology Medical terminology and medical coding knowledge desired.Willingness to continually learn and grow as a member of a Team and DepartmentSKILLS / ABILITIES / COMPETENCIES REQUIRED :
Basic knowledge of Outlook, word and excel. Will train in department database system.Ability of work independently and prioritize work.Excellent customer service and communication skillsGood organizational skills required to handle multiple tasks in a busy environmentThe right candidate must have a positive attitude, quick mind, and thrive with working under strict timelines.
Additional Job Description
The General Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and / or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
