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Prior Authorization Reviewer
The US Oncology Network. Review, process, and audit medical necessity for each patient chemotherapy treatment and documentation of regimen relative to pathway adherence .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical insurance verification and authorization, particularly for chemotherapy services, while maintaining compliance with state and federal regulations. Strong ability to communicate effectively with patients and healthcare staff regarding insurance processes and pathway adherence.
Highest-signal resume keywords
Medical Insurance VerificationChemotherapy Authorization RequirementsLPN State LicenseRegulatory Guidelines KnowledgePatient Advocacy
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Chemotherapy Treatment ReviewInsurance AuthorizationPathway DocumentationCoding Guidelines UpdateBusiness Office Functions
Soft Skills
Decision MakingTime ManagementAdaptabilityPerformance Standards SettingQuality Improvement
Certifications & Qualifications
LPN State LicenseAssociates Degree in Healthcare
Industry Keywords
US Oncology Compliance ProgramHIPAA LawsPatient Records ConfidentialityInsurance Plan RestrictionsCommunity Resources
About the role
Key responsibilities & impact- Review, process, and audit medical necessity for each patient chemotherapy treatment and documentation of regimen relative to pathway adherence
- Communicate insurance-plan restrictions and special requirements to nursing and medical staff
- Provide feedback to physicians and management regarding pathway documentation and payer issues involving non-covered chemotherapy drugs
- Update coding and payer guidelines for clinical staff
- Track pathways and perform other business office functions as needed
- Obtain insurance authorization and pre-certification for chemotherapy services
- Act as a patient advocate and liaison between patients and payers to answer reimbursement questions and avoid insurance delays
- Research additional or alternative resources for non-covered chemotherapy services to prevent payment denials
- Provide patients with contact lists for community resources, special programs, drugs, pharmaceutical supplies, and financial resources
- Maintain working knowledge of chemotherapy authorization requirements for all payers and applicable regulatory guidelines
- Support and adhere to the US Oncology Compliance Program, including the Code of Ethics and Business Standards
- Perform other duties as requested or assigned
Requirements
What you’ll need- High school degree or equivalent
- Associates degree in Healthcare preferred
- LPN state license and registration preferred
- Minimum three (3) years medical insurance verification and authorization required
- Up-to-date knowledge of the profession and industry
- Knowledge of chemotherapy authorization requirements for all payers
- Knowledge of state and federal regulatory guidelines for coverage and authorization
- Adherence to confidentiality, state, federal, and HIPPA laws and guidelines regarding patient records
- Ability to handle multiple demands, shifting priorities, ambiguity, and rapid change
- Ability to make timely, cost-effective, and sound decisions
- Ability to set high performance standards and pursue aggressive goals
- Ability to deliver quality products and services and improve efficiencies
- Ability to perform required physical functions, including sitting, standing, talking, hearing, walking, lifting, manual dexterity, and eye-hand coordination
- Ability to occasionally lift and carry items weighing up to 40 lbs.
- Corrected vision and hearing within the normal range
Benefits
Comp & perks- Medical Health Care
- Dental Care
- Vision Plan
- 401-K with a matching component
- Life Insurance
- Short-term and Long-term disability
- Wellness & Perks Programs
- Forward-thinking, advancement opportunities, and an inspired work environment