Description

Purpose:
Responsible for review of all patients requiring chemotherapy and adjunctive infusions, including confirmation of patient insurance benefits, reimbursement, and determination of any patient responsibility. Communicates findings with clinical team and patient. Reviews open accounts to evaluate claim status and intervenes appropriately to assure proper payment. Works with patients to determine availability of oncology specific assistance programs.

Responsibilities:

• Obtains payor specific pre-determination and/or prior authorization procedures and documentation requirements. If applicable facilitates the prior authorization process for patients and healthcare providers.
  
• Determine medical necessity based on current policies, and stays updated on clinical bulletins with individual insurance carriers. 
• Collect coinsurance and deductibles from patients as appropriate.
• Reviews accounts without insurance, verifies MA application process, charity care application and/or drug replacement program availability. 
• Researches rejections and investigates problems, resubmitting and/or appealing claims where appropriate.  
  
  

Qualifications

• B.A. degree in health care administration, business and/or other related discipline (Related experience may be substituted for educational requirements). 
• Masters Degree preferred. 
• 5-10 years experience with either a physician practice, hospital, ancillary provider, health insurance company or integrated delivery system is required. 
• Individual needs to have in depth understanding of managed care delivery systems and have had direct experience with reimbursement. 
• Excellent planning, communication, documentation, organizational, analytical, and problem solving abilities. 
• Advanced mathematical skills. 
• Ability to interpret and summarize results of various analysis in a timely and meaningful way.
• Strong computer skills, including expert knowledge of Access and Excel.
• Knowledge of ICD-9CM, CPT4, Revenue Codes, DRG's, base rates, Medicare methodologies, Medicaid methodologies, HCPCS coding and related governmental guidelines and provider reimbursement methodologies required.
• Knowledge of fee schedules, case rates, per-diems, RUG III.
• Ability to work cooperatively with multidisciplinary teams and/or independently.
• Ability to re-engineer processes to positively impact productivity in terms of timeliness and accuracy. 
• Ability to furnish finished reports.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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